Genetic Polymorphisms Predictive of Nutritional Requirements for Choline in Subjects

ABSTRACT

Methods of predicting susceptibility of a subject to develop one or more choline deficiency-associated health effects are provided, comprising determining a genotype of the subject with respect to at least one choline metabolism gene and comparing the genotype of the subject with at least one reference genotype associated with susceptibility to develop the one or more choline deficiency-associated health effects.

RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional PatentApplication Ser. No. 60/723,979, filed Oct. 5, 2005, the disclosure ofwhich is incorporated herein by reference in its entirety.

GOVERNMENT INTEREST

This invention was made with U.S. Government support under Grant Nos.DK55865, AG09525, ES012997, RR00046, and ES10126 awarded by the NationalInstitutes of Health. As such, the U.S. Government has certain rights inthe invention.

TECHNICAL FIELD

The presently disclosed subject matter relates to predicting thesusceptibility of a subject to develop one or more cholinedeficiency-associated health effects based upon determined genotypes ofthe subject.

BACKGROUND

Choline is a required nutrient, and the Institute of Medicine and theNational Academy of Sciences of the U.S.A. set an adequate intake levelfor choline of 550 mg/day for men and 425 mg/day for women. Choline orits metabolites are needed for the structural integrity and signalingfunctions of cell membranes. It is the major source of methyl groups inthe diet (one of choline's metabolites, betaine, participates in themethylation of homocysteine to form methionine), and it directly affectscholinergic neurotransmission, transmembrane signaling, and lipidtransport/metabolism (Zeisel & Blusztajn (1994)).

One of the clinical consequences of dietary choline deficiency can bethe development of fatty liver (hepatosteatosis) (Buchman et al. (1995);Zeisel et al. (1991)), because a lack of phosphatidylcholine limits theexport of excess triglyceride from liver (Yao & Vance (1988); Yao &Vance (1989)). Also, choline deficiency induces hepatocyte apoptosiswith leakage of alanine aminotransferase from liver into blood (Zeiselet al. (1991); Albright et al. (1996); Albright at al. (2005)). Somesubjects, when deprived of choline, develop muscle damage and increasedcreatine kinase (CK) activity in blood (da Costa et al. (2004)). Thiseffect may be attributable to impaired membrane stability as aconsequence of diminished availability of phosphatidylcholine. The risein blood CK levels can be a surrogate marker for choline depletionstatus.

Women's dietary requirements for choline are of special interest becausedeficient maternal dietary intake of choline during pregnancy in humanshas been associated with a 4-fold increased risk of having a baby with aneural tube defect (Shaw et al. (2004)). In addition, offering pregnantrodents diets deficient in choline resulted in perturbed braindevelopment in their fetuses (Albright et al. (1999a); Albright et al.(1999b); Jones et al. (1999); Meck & Williams (1999)).

The factors that influence different dietary requirements for choline inanimals, including humans, are not completely understood. Variationbetween individuals in activity levels of, and interactions between,proteins involved with choline metabolism can potentially affect dietaryrequirements, which in turn can result from genetic variation of genesencoding choline metabolism proteins. Thus, there is an unmet need forcharacterization of how genetic variation in genes encoding cholinemetabolism proteins can be predictive of nutritional requirements forcholine.

SUMMARY

This Summary lists several embodiments of the presently disclosedsubject matter, and in many cases lists variations and permutations ofthese embodiments. This Summary is merely exemplary of the numerous andvaried embodiments. Mention of one or more representative features of agiven embodiment is likewise exemplary. Such an embodiment can typicallyexist with or without the feature(s) mentioned; likewise, those featurescan be applied to other embodiments of the presently disclosed subjectmatter, whether listed in this Summary or not. To avoid excessiverepetition, this Summary does not list or suggest all possiblecombinations of such features.

In some embodiments of the presently disclosed subject matter, a methodof predicting susceptibility of a subject to develop one or more cholinedeficiency-associated health effects is provided. In some embodiments,the method comprises determining a genotype of the subject with respectto at least one choline metabolism gene and comparing the genotype ofthe subject with at least one reference genotype associated withsusceptibility to develop the one or more choline deficiency-associatedhealth effects, wherein the reference genotype is at least one genotypeof a choline metabolism gene.

In some embodiments of the presently disclosed subject matter, a methodof treating one or more choline deficiency-associated health effects ina subject is provided. In some embodiments the method comprisesdetermining a genotype of the subject with respect to at least onecholine metabolism gene; comparing the determined genotype of thesubject with at least one reference genotype associated withsusceptibility to develop one or more choline deficiency-associatedhealth effects, wherein the reference genotype is at least one genotypeof a choline metabolism gene; and administering to the subject aneffective amount of a choline supplement composition, based on thedetermined genotype being associated with susceptibility to develop oneor more choline deficiency-associated health effects.

In some embodiments of the presently disclosed subject matter, a methodof predicting activity of a choline metabolism polypeptide in a subjectis provided. In some embodiments, the method comprises determining agenotype of the subject with respect to at least one choline metabolismgene; and comparing the genotype of the subject with at least onereference genotype associated with activity of a choline metabolismpolypeptide, wherein the reference genotype is at least one genotype ofa choline metabolism gene.

In some embodiments of the methods disclosed herein, determining thegenotype of the subject comprises:

(a) identifying at least one polymorphism of the at least one cholinemetabolism gene;

(b) identifying at least one haplotype of the at least one cholinemetabolism gene;

(c) identifying at least one polymorphism unique to at least onehaplotype of the at least one choline metabolism gene;

(d) identifying at least one polymorphism exhibiting high linkagedisequilibrium to at least one polymorphism unique to the at least onecholine metabolism gene;

(e) identifying at least one polymorphism exhibiting high linkagedisequilibrium to the at least one choline metabolism gene; or

(f) combinations thereof.

In some embodiments of the methods disclosed herein, the cholinemetabolism gene is selected from the group including but not limited tophosphatidylethanolamine N-methyltransferase (PEMT), cholinedehydrogenase (CHDH), 5,10-methylenetetrahydrofolate dehydrogenase 1(MTHFD1), betaine: homocysteine methyltransferase (BHMT), 5,10-methylenetetrahydrofolate reductase (MTHFR), reduced folate carrier 1 (RFC1),ATP-binding cassette sub-family B member 4 (ABCB4), solute carrierfamily 44 member 1 (SLC44A1), choline kinase alpha (CHKA), and cholinekinase beta (CHKB) and combinations thereof. Further, in someembodiments, the reference genotype is selected from the group includingbut not limited to a PEMT genotype, a CHDH genotype, an MTHFD1 genotype,a BHMT genotype, an MTHFR genotype, a RFC1 genotype, an ABCB4 genotype,a SLC44A1 genotype, a CHKA genotype, a CHKB genotype, and combinationsthereof.

In some embodiments of the methods disclosed herein, the referencegenotype is a PEMT genotype comprising a G-774C (rs12325817)polymorphism. In some embodiments, the determined genotype of thesubject with respect to PEMT comprises at least one copy of a PEMTrs12325817 C allele. In some embodiments, the reference genotype is aCHDH genotype comprising a G432T (rs12676) polymorphism. In someembodiments, the determined genotype of the subject with respect to CHDHcomprises at least one copy of a CHDH rs12676 T allele. In someembodiments, the reference genotype is a CHDH genotype comprising aA318C (rs9001) polymorphism. In some embodiments, the determinedgenotype of the subject with respect to CHDH comprises at least one copyof a CHDH rs9001 C allele. In some embodiments, the reference genotypeis a MTHFD1 genotype comprising a G1958A (rs2236225) polymorphism. Insome embodiments, the determined genotype of the subject with respect toMTHFD1 comprises at least one copy of a MTHFD1 rs2236225 A allele.

In some embodiments of the methods disclosed herein, the one or morecholine deficiency-associated health effects are selected from the groupincluding but not limited to transmembrane signaling dysfunction,cholinergic neurotransmission dysfunction, lipid transport dysfunction,lipid metabolism dysfunction, organ dysfunction, liver dysfunction,fatty liver, congenital birth defects, and combinations thereof. In someembodiments, the one or more choline deficiency-associated healtheffects are associated with an insufficient dietary intake of choline bythe subject. In some embodiments, the subject is the subject is apremenopausal female subject. In some embodiments, the subject is apregnant subject and the one or more choline deficiency-associatedhealth effects comprise one or more congenital birth defects (e.g.,neural tube defects) to a fetus carried by the subject. In otherembodiments, the subject is receiving substantially all nutritionalsustenance parenterally and the one or more cholinedeficiency-associated health effects comprise liver dysfunction.

Accordingly, it is an object of the presently disclosed subject matterto provide methods for predicting and/or treating one or more cholinedeficiency-associated health effects in a subject. This and otherobjects are achieved in whole or in part by the presently disclosedsubject matter.

An object of the presently disclosed subject matter having been statedhereinabove, other aspects and objects will become evident as thedescription proceeds when taken in connection with the accompanyingDrawings and Examples as best described herein below.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagram showing three genes involved in choline metabolismfor which single nucleotide polymorphisms were identified.PEMT=phosphatidylethanolamine N-methyltransferase, which catalyzes thereaction to make phosphatidylcholine (PtdCho) fromphosphatidylethanolamine (PtdEtn) using S-adenosylmethionine (SAM) todonate methyl groups; CHDH=choline dehydrogenase, which along withbetaine aldehyde dehydrogenase irreversibly oxidizes choline (Cho) toform betaine (Bet); BHMT=betaine:homocysteine methyltransferase, whichdonates its methyl group to homocysteine (Hcy) to form methionine (Met);PCho=phosphocholine.

FIG. 2 is a diagram showing three polymorphic genes that are involved infolate-mediated one-carbon transfer. THF, tetrahydrofolate; MTHFR,5,10-methylene tetrahydrofolate reductase; MTHFD1, cytosolic5,10-methylene tetrahydrofolate dehydrogenase; and RFC1, reduced folatecarrier 1.

FIG. 3 is a bar graph showing an increase in SAH concentrations after amethionine load was lower in MTFD1 1958 GG individuals. Subjects weretreated with a low-choline diet as described in Materials and Methodsfor Examples 1-3. Blood for SAM and SAH measurements was obtained before(fasting) and 4 hours after an oral methionine load (Met-load; 100 mg ofL-methionine per kg of body weight) from 26 individuals with MTHFD1 1958GA/AA genotype and from 15 individuals with MTHFD1 1958 GG genotype.Values are presented as mean+/−standard error. Solid bars indicate meansof individuals with the MTHFD1 1958 GA or AA genotypes, and open barscorrespond to means from those with the GG genotype. *, P<0.05; **,P<0.01 different from other genotype by one-way ANOVA.

FIG. 4 is a diagram showing the study design for Example 4. Healthy menand women were fed a baseline diet containing a defined choline adequateintake concentration as defined by the U.S. Institute of Medicine for 10days. They were then switched to a low choline diet (<50 mg choline)until they developed signs of organ dysfunction associated with cholinedeficiency or for up to 42 days. Subjects who developed signs of organdysfunction were repleted with graded amounts of choline at 10 dayintervals until their symptoms disappeared; those without signs of organdysfunction were fed the 100% choline diet for at least 3 days beforebeing discharged from the study. Some subjects were given a folic acidsupplement (400 μg per day) during the depletion and repletion phases,but this did not affect their susceptibility to choline deficiency.

Brief Description of the Tables

Table 1 shows a list of exemplary single nucleotide polymorphisms fromcholine metabolism genes that can be connected with cholinedeficiency-associated health effects.

Table 2 shows an exemplary research diet menu including actual amountsof food provided for a 2500 kilocalorie diet containing varying amountsof choline. *Percentages show the approximate amount of choline based onthe AI. **Wheat starch bread given on Depletion Diet and lecithin breadon Repletion Diets.

Table 3 shows effects of genotype on susceptibility to organ dysfunctionin humans eating low-calorie diets. Significance was calculated with a2×3 Fisher's exact test. Application of Bonferroni's correction formultiple testing lowers the threshold for statistical significance to0.0125.

Table 4 shows effects of folate and sex on effect of MTHFD1 1958 SNP onsusceptibility to organ dysfunction in humans eating low-choline diets.The odds ratios were calculated as the odds of showing signs ofdeficiency for subjects without the MTHFD1 1958A allele divided by theodds of showing signs of deficiency for subjects with the A allele.Two-sided P and 95% CI were calculated with Fisher's exact test. Theodds ratio for premenopausal women was calculated by adding a value of0.5 to each cell for premenopausal women.

Table 5 lists SNPs studied in Example 4. Each SNP is mapped to thegenome and assigned a reference SNP (RefSNP) accession ID (rs number).Base pair and sequence changes, also listed, are subject to revisionwhen genes are resequenced. Note (b): PEMT SNP base pair numbers arenumbered from transcription start site (Shields et al. (2001)).

Table 6 lists primers for sequencing the PEMT promoter region. Primerswere used to sequence the PEMT gene as described in the Materials andMethods of Example 4.

Table 7 lists effects of PEMT promoter SNP rs12325817 (G-744C) onsusceptibility to organ dysfunction in humans eating a low choline diet.Subjects were fed a diet low in choline, and some developed signs oforgan dysfunction (liver or muscle) that were reversed when choline wasadded back to their diets. Numbers of subjects are indicated for eachgenotype. Two-sided P values were calculated with a 2×3 Fisher exacttest. For P<0.05, odds ratios (OR) and 95% confidence intervals (CI)were calculated as the odds of showing signs of deficiency for subjectswith the C allele divided by the odds of showing signs of deficiency forsubjects without the C allele. Note (b): For postmenopausal andpremenopausal women (where some cells were 0), the odds ratio and 95%confidence intervals were computed after adding 0.5 to each cell, sothese values underestimate the true values.

Table 8 lists effects of choline dehydrogenase (CHDH) genotypes onsusceptibility to organ dysfunction in humans eating a low choline diet.Subjects were fed a diet low in choline and some developed signs oforgan dysfunction (liver or muscle), which reversed when choline wasadded back to their diets. Numbers of subjects are indicated for eachgenotype. Two-sided P values were calculated with a 2×3 Fisher exacttest. For P<0.05, odds ratios (OR) and 95% confidence intervals (CI)were calculated as the odds of showing signs of deficiency for subjectswith the C allele (T allele for CHDH 432) divided by the odds of showingsigns of deficiency for subjects without the C allele (T allele for CHDH432).

Table 9 lists data showing PEMT rs7946 (G5465A) and BHMT rs3733890(G742A) genotypes were not associated with changes in susceptibility toorgan dysfunction in humans eating a low choline diet. Subjects were feda diet low in choline and some developed signs of organ dysfunction(liver or muscle) that reversed when choline was added back to theirdiets. Numbers of subjects are indicated for each genotype. Two-sided Pvalues were calculated with a 2×3 Fisher exact test.PEMT=phosphatidylethanolamine N-methyltransferase;BHMT=betaine:homocysteine methyltransferase.

DETAILED DESCRIPTION

Factors that influence the dietary requirement for choline in animalsinclude dietary availability of methyl donors (Zeisel & Blusztajn(1994)) other than choline and endogenous de novo biosynthesis ofcholine moieties (Bremer & Greenberg (1961)), for example. Each of thesefactors and others are further influenced by individual geneticvariability within genes involved in choline metabolism. As such, somesubjects deplete quickly when fed a low-choline diet, whereas others donot. The presently disclosed subject matter provides for thedetermination of genetic polymorphisms in subjects, which can beutilized to predict individual choline needs and thereforesusceptibility to adverse health effects resulting from cholinedeficiency.

Endogenous production of choline during phosphatidylcholine biosynthesis(through the methylation of phosphatidylethanolamine byphosphatidylethanolamine N-methyltransferase) is most active in liver,but has been identified in many other tissues, including the brain andthe mammary gland (Vance et al. (1997); Blusztajn et al. (1985); Yang etal. (1988)). This synthesis of choline provides some, but not all of thecholine required to sustain normal organ function in humans (Zeisel etal. (1991)).

The use of choline as a methyl-group donor also influences the dietaryrequirement for choline. For example, the methylation of homocysteine toform methionine can be accomplished by using a methyl group derived fromone-carbon metabolism or by using a methyl group derived from choline.When choline is used as a methyl group source (see FIGS. 1 and 2), it isfirst irreversibly oxidized to form betaine by choline dehydrogenase(CHDH) and is no longer available for, for example, synthesis ofmembrane phosphatidylcholine.

The metabolism of choline, methionine, and methylfolate are closelyinterrelated and intersect at the formation of methionine fromhomocysteine (FIG. 2). Betaine:homocysteine methyltransferase (BHMT)catalyzes the remethylation of homocysteine by using the cholinemetabolite betaine as the methyl donor (Sunden et al. (1997); Millian &Garrow (1998)). In an alternative pathway,5-methyltetrahydrofolate:homocysteine S-methyltransferase (also known asmethionine synthase) regenerates methionine by using a methyl groupderived de novo from the one-carbon pool (Bailey & Gregory (1999)).Perturbing the metabolism of one of the methyl donors results incompensatory changes in the other methyl donors because of theintermingling of these metabolic pathways (Kim et al. (1995); Selhub etal. (1991); Varela-Moreiras et al. (1992); Zeisel et al. (1989)).

For example, rats ingesting a low-choline diet showed diminished tissueconcentrations of methionine and S-adenosylmethionine (SAM) (Zeisel etal (1989)) and of total folate (Selhub et al. (1991)). Humans deprivedof dietary choline have difficulty removing homocysteine after amethionine load and develop elevated plasma homocysteine concentrations(da Costa et al. (2005)). Methotrexate, which is widely used in thetreatment of cancer, psoriasis, and rheumatoid arthritis, limits theavailability of methyl groups by competitively inhibiting dihydrofolatereductase, a key enzyme in intracellular folate metabolism. Rats treatedwith methotrexate have diminished pools of all choline metabolites inliver (Pomfret et al. (1990)). Choline supplementation reverses thefatty liver caused by methotrexate administration (Freeman-Narrod et al.(1977); Aarsaether et al. (1988); Svardal et al. (1988)). Geneticallymodified mice with defective 5,10-methylene tetrahydrofolate reductase(MTHFR) activity become choline-deficient (Schwahn et al. (2003)), asignificant observation because many animals, including humans, havegenetic polymorphisms that alter the activity of this enzyme (Rozen, R.(1996); Wilcken et al. (1996)).

As noted, genetic variations (e.g., single nucleotide polymorphisms(SNPs)) exist in choline metabolism genes in animals, including humans.However, those genetic variations that have functional effects oncholine metabolism, and thereby the nutritional requirements forcholine, have not been identified prior to the presently disclosedsubject matter. For example, if decreased availability of methyl groupsfrom choline is responsible for organ dysfunction in choline deficiency,then particular SNPs in CHDH or BHMT could possibly alter susceptibilityto developing organ dysfunction when fed a low choline diet.Alternatively, if organ damage is due to defective membrane formation,SNPs in PEMT encoding phosphatidylethanolamine N-methyltransferase(PEMT), which catalyzes phosphatidylcholine formation from SAM (FIG. 1),can modify de novo phosphatidylcholine synthesis and SNPs resulting indecreased CHDH activity could decrease the use of choline as a methyldonor and make more substrate available for phosphatidylcholinesynthesis from preexisting choline moiety, thereby alteringsusceptibility to developing organ dysfunction when fed a low cholinediet. Thus, SNPs in genes involved in choline metabolism, includingfolate metabolism, can potentially increase the demands for choline as amethyl-group donor, thereby increasing dietary requirements for thisessential nutrient.

The presently disclosed subject matter provides new insights into themolecular pathways involved in the development of cholinedeficiency-associated health effects and further reveals genotypes,including genetic polymorphisms present in subjects, which can produce aclinical phenotype that is vulnerable to the development of one or morecholine deficiency-associated health effects. The genotypes (which caninclude genetic polymorphisms) identified herein are useful forpredicting the susceptibility of a subject to develop one or morecholine deficiency-associated health effects, including for exampleorgan dysfunction and congenital birth defects. The disclosed genotypescan also be utilized to predict the expression level and/or activity ofpeptides encoded by one or more choline metabolism genes.

The presently disclosed subject matter also provides methods forutilizing the knowledge of the genotype (which can include the presenceof polymorphisms (see e.g., Table 1) of a particular subject to treatthe subject for one or more choline deficiency-associated healtheffects. The treatment can be administered to the subject either beforethe onset of symptoms and in anticipation thereof based on a determinedgenotype of the subject, or after occurrence of symptoms associated withcholine deficiency-associated health effects and confirmation of asusceptible genotype in the subject.

Therefore, determining a subject's genotype for choline metabolismgenes, including but not limited to phosphatidylethanolamineN-methyltransferase (PEMT), choline dehydrogenase (CHDH), betaine:homocysteine methyltransferase (BHMT), methylenetetrahydrofolatedehydrogenase 1 (MTHFD1), 5,10-methylene tetrahydrofolate reductase(MTHFR), reduced folate carrier 1 (RFC1), ATP-binding cassettesub-family B member 4 (ABCB4), solute carrier family 44 member 1(SLC44A1), choline kinase alpha (CHKA), choline kinase beta (CHKB), andcombinations thereof can be used to predict the susceptibility of thesubject to develop choline deficiency-associated health effects, predictthe activity of a peptide encoded by one or more choline metabolismgenes, and/or to select effective treatments for the subject, asdisclosed in detail herein.

I. Definitions

While the following terms are believed to be well understood by one ofordinary skill in the art, the following definitions are set forth tofacilitate explanation of the presently disclosed subject matter.

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood to one of ordinary skill inthe art to which the presently disclosed subject matter belongs.Although any methods, devices, and materials similar or equivalent tothose described herein can be used in the practice or testing of thepresently disclosed subject matter, representative methods, devices, andmaterials are now described.

Following long-standing patent law convention, the terms “a”, “an”, and“the” refer to “one or more” when used in this application, includingthe claims. Thus, for example, reference to “a cell” includes aplurality of such cells, and so forth.

Unless otherwise indicated, all numbers expressing quantities ofingredients, reaction conditions, and so forth used in the specificationand claims are to be understood as being modified in all instances bythe term “about”. Accordingly, unless indicated to the contrary, thenumerical parameters set forth in this specification and attached claimsare approximations that can vary depending upon the desired propertiessought to be obtained by the presently disclosed subject matter.

As used herein, the term “about,” when referring to a value or to anamount of mass, weight, time, volume, concentration or percentage ismeant to encompass variations of in some embodiments ±20%, in someembodiments ±10%, in some embodiments ±5%, in some embodiments ±1%, insome embodiments ±0.5%, and in some embodiments ±0.1% from the specifiedamount, as such variations are appropriate to perform the disclosedmethod.

A “choline metabolism gene” as used herein refers to a polynucleotideexpressing a protein that functions, at least in part, in the metabolismof choline. “Choline metabolism” as used herein is intended to encompassall physiological aspects of choline production, function, anddegradation, including but not limited to choline synthesis andcatabolism, as well as choline use within other metabolic pathways,including for example the physiological utilization of choline in methyldonation reactions (e.g., folate-mediated one-carbon transfer). Cholineand folate metabolism are interrelated and therefore, the term “cholinemetabolism” is intended to include folate metabolism as well. Exemplarynon-limiting pathways of choline metabolism are shown in FIGS. 1 and 2and each of the proteins disclosed in these pathways are specificallyintended to be included within the definition of a protein thatfunctions in the metabolism of choline (i.e., a choline metabolismprotein). Thus, in some embodiments a choline metabolism gene is apolynucleotide encoding, for example, PEMT, CHDH, MTHFD1, BHMT, MTHFR,RFC1, ABCB4, SLC44A1, CHKA, or CHKB.

“PEMT gene” as used herein refers in some embodiments to a gene encodinga phosphatidylethanolamine N-methyltransferase protein (PEMT) and/orassociated regulatory sequences. PEMT transfers methyl groups betweenmolecules and can function to catalyze a reaction to producephosphatidylcholine (PtdCho) from phosphatidylethanolamine (PtdEtn)using S-adenosylmethionine (SAM) to donate methyl groups. An exemplaryPEMT gene can be a human PEMT gene located within a PEMT locus onchromosome 17 (GENBANK® Accession No. NC_(—)000017) between aboutnucleotide positions 17,349,830 and 17,435,665.

“CHDH gene” as used herein refers in some embodiments to a gene encodinga choline dehydrogenase protein (CHDH) and/or associated regulatorysequences. CHDH can function to irreversibly oxidize choline to formbetaine. An exemplary CHDH gene can be a human CHDH gene located withina CHDH locus on chromosome 17 (GENBANK® Accession No. NC_(—)000003)between about nucleotide positions 53,826,844 and 53,833,075.

“MTHFD1 gene” as used herein refers in some embodiments to a geneencoding a cytosolic 5,10-methylene tetrahydrofolate dehydrogenase(MTHFD1) protein and/or associated regulatory sequences. MTHFD1catalyzes the transfer of hydrogens from donor to acceptor molecules.MTHFD1 can catalyze the conversion of 5,10-methylene tetrahydrofolate to10-formyl tetrahydrofolate, and vice versa. An exemplary MTHFD1 gene canbe a human MTHFD1 gene located within a MTHFD1 locus on chromosome 14(GENBANK® Accession No. NC_(—)000014) between about nucleotide positions63,924,899 and 63,994,774.

“BHMT” gene as used herein refers in some embodiments to a gene encodinga betaine:homocysteine methyltransferase (BHMT) protein and/orassociated regulatory sequences. BHMT catalyzes the transfer of a methylgroup to homocysteine from betaine to form methionine. An exemplary BHMTgene can be a human BHMT gene located within a BHMT locus on chromosome5 (GENBANK® Accession No. NC_(—)000005) between about nucleotidepositions 78,443,465 and 78,462,695.

“MTHFR” gene as used herein refers in some embodiments to a geneencoding a 5,10-methylene tetrahydrofolate reductase (MTHFR) proteinand/or associated regulatory sequences. MTHFR can catalyze theconversion of 5,10-methylene tetrahydrofolate to 5-methyltetrahydrofolate. An exemplary MTHFR gene is a human MTHFR gene locatedwithin a MTHFR locus on chromosome 1 (GENBANK® Accession No.NC_(—)000001) between about nucleotide positions 11,773,324 and11,785,760.

“RFC1” gene as used herein refers in some embodiments to a gene encodinga reduced folate carrier 1 (RFC1) protein and/or associated regulatorysequences. RFC1 can function, for example, as a folate transporterprotein. An exemplary RFC1 gene is a human RFC1 gene located within aRFC1 locus on chromosome 4 (GENBANK® Accession No. NC_(—)000004).

“ABCB4” gene as used herein refers in some embodiments to a geneencoding a ATP-binding cassette, sub-family B, member 4 (ABCB4) proteinand/or associated regulatory sequences. ABCB4 is a transmembrane proteinthat can bind ATP and use the energy to drive the transport of variousmolecules across all cell membranes. An exemplary ABCB4 gene is a humanABCB4 gene located within a ABCB4 locus on chromosome 7 (GENBANK®Accession No. NC_(—)000007) between about nucleotide positions86,869,348 and 86,942,717.

“SLC44A1” gene as used herein refers in some embodiments to a geneencoding a solute carrier family 44, member 1 (SLC44A1) protein and/orassociated regulatory sequences. SLC44A1 can transport cholinemolecules. An exemplary SLC44A1 gene is a human SLC44A1 gene locatedwithin a SLC44A1 locus on chromosome 9 (GENBANK® Accession No.NC_(—)000009).

“CHKA” gene as used herein refers in some embodiments to a gene encodinga choline kinase alpha (CHKA) protein and/or associated regulatorysequences. CHKA can phosphorylate choline molecules. An exemplary CHKAgene is a human CHKA gene located within a CHKA locus on chromosome 11(GENBANK® Accession No. NC_(—)000011) between about nucleotide positions67,567,632 and 67,645,220.

“CHKB” gene as used herein refers in some embodiments to a gene encodinga choline kinase beta (CHKB) protein and/or associated regulatorysequences. CHKB can phosphorylate choline molecules. An exemplary CHKBgene is a human CHKB gene located within a CHKB locus on chromosome 22(GENBANK® Accession No. NC_(—)000022) between about nucleotide positions49,364,476 and 49,368,076.

As used herein, the term “expression” generally refers to the cellularprocesses by which an RNA is produced by RNA polymerase (RNA expression)or a polypeptide is produced from RNA (protein expression).

The term “gene” is used broadly to refer to any segment of DNAassociated with a biological function. Thus, genes include, but are notlimited to, coding sequences and/or the regulatory sequences requiredfor their expression. Genes can also include non-expressed DNA segmentsthat, for example, form recognition sequences for a polypeptide. Genescan be obtained from a variety of sources, including cloning from asource of interest or synthesizing from known or predicted sequenceinformation, and can include sequences designed to have desiredparameters.

As used herein, the term “DNA segment” means a DNA molecule that hasbeen isolated free of total genomic DNA of a particular species.Included within the term “DNA segment” are DNA segments and smallerfragments of such segments, and also recombinant vectors, including, forexample, plasmids, cosmids, phages, viruses, and the like.

As used herein, the term “genotype” means the genetic makeup of anorganism. Expression of a genotype can give rise to an organism'sphenotype, i.e. an organism's physical traits. The term “phenotype”refers to any observable property of an organism, produced by theinteraction of the genotype of the organism and the environment. Aphenotype can encompass variable expressivity and penetrance of thephenotype. Exemplary phenotypes include but are not limited to a visiblephenotype, a physiological phenotype, a susceptibility phenotype, acellular phenotype, a molecular phenotype, and combinations thereof. Thephenotype can be related to choline metabolism and/or cholinedeficiency-associated health effects. As such, a subject's genotype whencompared to a reference genotype or the genotype of one or more othersubjects can provide valuable information related to current orpredictive phenotypes.

“Determining the genotype” of a subject, as used herein, can refer todetermining at least a portion of the genetic makeup of an organism andparticularly can refer to determining a genetic variability in thesubject that can be used as an indicator or predictor of phenotype. Thegenotype determined can be the entire genome of a subject, but far lesssequence is usually required. The genotype determined can be as minimalas the determination of a single base pair, as in determining one ormore polymorphisms in the subject (see e.g., Table 1). Further,determining a genotype can comprise determining one or more haplotypes.Still further, determining a genotype of a subject can comprisedetermining one or more polymorphisms exhibiting high linkagedisequilibrium to at least one polymorphism or haplotype havinggenotypic value.

As used herein, the term “polymorphism” refers to the occurrence of twoor more genetically determined alternative variant sequences (i.e.,alleles) in a population. A polymorphic marker is the locus at whichdivergence occurs. Preferred markers have at least two alleles, eachoccurring at a frequency of greater than 1%. A polymorphic locus may beas small as one base pair (e.g., a single nucleotide polymorphism(SNP)). Exemplary SNPs are disclosed herein and can be referenced byaccession number (e.g., “rs number”) and/or SEQ ID NO. Both rs numbers(searchable through NCBI's Entrez SNP website) and SEQ ID NOs comprisethe SNP as well as proximate contiguous nucleotides provided to placethe SNP in context within the gene. Thus, rs numbers and/or SEQ ID NOsreferenced herein are intended to indicate the presence of the SNP andnot to require the presence of all or part of the contiguous nucleotidesequence disclosed therein. Further, reference to a particularpolymorphism is intended to also encompass the complementarynucleotide(s) on the complementary nucleotide strand (e.g., coding andnon-coding polynucleotides).

As used herein, “haplotype” means the collective characteristic orcharacteristics of a number of closely linked loci with a particulargene or group of genes, which can be inherited as a unit. For example,in some embodiments, a haplotype can comprise a group of closely relatedpolymorphisms (e.g., single nucleotide polymorphisms (SNPs)). In someembodiments, the determined genotype of a subject can be particularhaplotypes for one or more of PEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1,ABCB4, SLC44A1, CHKA, and CHKB.

As used herein, “linkage disequilibrium” (LD) means a derivedstatistical measure of the strength of the association or co-occurrenceof two independent genetic markers. Various statistical methods can beused to summarize LD between two markers but in practice only two,termed D′ and r2, are widely used, as is generally known in the art.

In some embodiments, determining the genotype of a subject can compriseidentifying at least one polymorphism (e.g., an SNP) of at least onegene, such as for example PEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1, ABCB4,SLC44A1, CHKA, CHKB, and combinations thereof. In some embodiments,determining the genotype of a subject can comprise identifying at leastone haplotype of a gene, such as for example PEMT, CHDH, BHMT, MTHFD1,MTHFR, RFC1, ABCB4, SLC44A1, CHKA, CHKB, and combinations thereof. Insome embodiments, determining the genotype of a subject can compriseidentifying at least one polymorphism unique to at least one haplotypeof a gene, such as for example PEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1,ABC84, SLC44A1, CHKA, CHKB, and combinations thereof. In someembodiments, determining the genotype of a subject can compriseidentifying at least one polymorphism exhibiting high linkagedisequilibrium to at least one polymorphism unique to at least onehaplotype, such as for example PEMT haplotype, CHDH haplotype, BHMThaplotype, MTHFD1 haplotype, MTHFR haplotype, RFC1 haplotype, ABCB4haplotype, SLC44A1 haplotype, CHKA haplotype, CHKB haplotype, orcombinations thereof. In some embodiments, determining the genotype of asubject can comprise identifying at least one polymorphism exhibitinghigh linkage disequilibrium to at least one haplotype, such as forexample PEMT haplotype, CHDH haplotype, BHMT haplotype, MTHFD1haplotype, MTHFR haplotype, RFC1 haplotype ABCB4 haplotype, SLC44A1haplotype, CHKA haplotype, CHKB haplotype, or combinations thereof.Table 1 provides an exemplary non-limiting list of SNPs that can becorrelated with choline deficiency-associated health effects.

As used herein, the term “modulate” means an increase, decrease, orother alteration of any, or all, chemical and biological activities orproperties of a wild-type or mutant polypeptide, such as for examplePEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1, ABCB4, SLC44A1, CHKA, CHKB orcombinations thereof. A peptide activity can be modulated at either thelevel of expression, e.g., modulation of gene expression (for example,due to polymorphisms within the regulatory sequences of a gene), or atthe level of protein activity (e.g., polymorphism resulting in aminoacid changes affecting protein activity). The term “modulation” as usedherein refers to both upregulation (i.e., activation or stimulation) anddownregulation (i.e. inhibition or suppression) of an expression leveland/or activity level.

As used herein, the term “mutation” carries its traditional connotationand means a change, inherited, naturally occurring or introduced, in anucleic acid or polypeptide sequence, and is used in its sense asgenerally known to those of skill in the art.

As used herein, the term “polypeptide” means any polymer comprising anyof the 20 protein amino acids, regardless of its size. Although“protein” is often used in reference to relatively large polypeptides,and “peptide” is often used in reference to small polypeptides, usage ofthese terms in the art overlaps and varies. The term “polypeptide” asused herein refers to peptides, polypeptides and proteins, unlessotherwise noted. As used herein, the terms “protein”, “polypeptide” and“peptide” are used interchangeably herein when referring to a geneproduct.

“Choline deficiency-associated health effects” as used herein refers toclinical conditions and symptoms directly or indirectly resulting frominsufficient amounts of choline within the particular subject. Amountsof choline required by individual subjects vary depending on multiplefactors, including genetic variation between individuals of cholinemetabolism genes, as disclosed herein. Therefore, the amount of cholinerequired by a particular subject to prevent or treat cholinedeficiency-associated health effects can vary significantly.Determination of a subject's genotype with regard to choline metabolismgene(s) can help predict susceptibility of a subject to cholinedeficiency-associated health effects. Exemplary cholinedeficiency-associated health effects include, but are not limited totransmembrane signaling dysfunction, cholinergic neurotransmissiondysfunction, lipid transport dysfunction, lipid metabolism dysfunction,organ dysfunction, liver dysfunction, fatty liver, congenital birthdefects, and combinations thereof. Congenital birth defects can include,but are not limited to, neural tube defects (e.g., spina bifida).

As used herein, “significance” or “significant” relates to a statisticalanalysis of the probability that there is a non-random associationbetween two or more entities. To determine whether or not a relationshipis “significant” or has “significance”, statistical manipulations of thedata can be performed to calculate a probability, expressed as a“p-value”. Those p-values that fall below a user-defined cutoff pointare regarded as significant. A p-value in some embodiments less than orequal to 0.05, in some embodiments less than 0.01, in some embodimentsless than 0.005, and in some embodiments less than 0.001, are regardedas significant.

TABLE 1 SEQ GENE/SNP ID ID No Proximate Sequence and [polymorphism] NOPEMT rs12325817 cagoctqqacaacatggtgacactc[G/C]gtctctactaaaaatacaaaaatag 1 rs2278952 CCTGCAGCTCAGCAGACCTCCTGGC[C/T]GTGGTGGGTAGCTCCTTTCCTTTAG  2rs7946 ACTCACTCTTCGTATAGGAGAGCCA[C/T]TATGTAGGTGAGGGCCACCAGCACC  3rs8068641 CGATCCCCTGCATGTGGGGCTCACC[A/G]AGCAGTGGGATACTCCCGTCTGGAC  4rs7224725 CTATCTCTGGCCATACTCTCAGCCA[C/T]CCTAAAAGTAAAGCCTTGTTGTTAG  5rs956967 CAGTTTCCTTGGGTTTCAAGACCCA[A/G]AAGCACTCACTTTTATCCTTGTCCC  6rs9944423 AGATTAAGCAACTAACACTGGGGGA[A/G]CCCAGCAGCAGCTGACATCCACCTG  7rs3760188 TGGGGTGAAGCTCACAACCAGCAGA[A/G]GAGTGAGAAGAGGCAGCCCAGCGTG  8rs7215880 AGGCCCTGCCACCGAGCTGTTCGTT[A/G]CCTCGGCTCCCGGGTTCCCAGATCT  9rs7217778 GGGAGGTGCCAGATGTGCCAAGTGT[G/T]AGGGCAGGGCAAACAAGGCAAGACG 10rs7215833 CAGCTAGGTGATAATTACTAATCTC[C/T]GCTACTGTGTATGGAAGACATCTTG 11rs4646341 CCAGAGAGTTCTCTGAAGGAGCTAA[C/T]ACCAGTTAGTGTTTTGAAGAGTAGC 12CHDH rs9001 AGCGCAGGCTCTGAGAGCCGGGACG[A/C]GTACAGCTATGTGGTGGTGGGCGCG 13rs12676 CTGGAGGCCGGGCCCAAGGACGTGC[G/T]CGCGGGGAGCAAGCGGCTCTCGTGG 14MTHFD1 rs2236225 TGGGCCAACAAGCTTGAGTGCGATC[C/T]GGTCTGCAATGATGGAGGAATTGCC15 ABCB4 rs1202283GCCGCGTATTGAGTTCAGTGGTGTC[A/G]TTGATGTCAAACCATCCTATTTCCT 16 rs8187797AGAAATTTGACACCCTGGTTGGAGA[C/G]AGAGGGGCCCAGCTGAGTGGTGGGC 17 rs8187801GGCGAGATCCTCACCAGAAGACTGC[A/G]GTCAATGGCTTTTAAAGCAATGCTA 18 rs8187799ACTAAATGATGAAAAGGCTGCCACT[A/G]GAATGGCCCCAAATGGCTGGAAATC 19 rs8187788CATAGCTCACGGATCAGGTCTCCCC[C/G]TCATGATGATAGTATTTGGAGAGAT 20 rs8187792TCACTGTTTCTTTTCTGTCCAGATA[C/G]TCTCGGCATTTAGTGACAAAGAACT 21 rs8187811AGGAGGTCAAAAACAGAGGATTGCT[A/G]TTGCCCGAGCCCTCATCAGACAACC 22 rs31655AGCCACTGGACATTGAGTTTCTTTG[C/T]TTCTTGACCATCGAGAAGCTGAAAA 23 MTHFRrs1801133 TTGAAGGAGAAGGTGTCTGCGGGAG[C/T]CGATTTCATCATCACGCAGCTTTTC 24rs1801131 TGGGGGGAGGAGCTGACCAGTGAAG[A/C]AAGTGTCTTTGAAGTCTTTGTTCTT 25BHMT rs3733890 ATGAAGGAGGGCTTGGAGGCTGCCC[A/G]ACTGAAAGCTCACCTGATGAGCCAG26 CHKA rs17857113CCCAAAGTAGCCTACCAACTCACCA[C/T]CTGCAAAATCGCTCCATACAGCCGC 27 rs17853642AATCTTGGCTTGTACAATGGACCAC[A/T]GTCCCCAGAGGAAATGAGATGCAAG 28 rs17853641ATTTCTGCAGAAATATCTGGCAAAC[C/T]TAATTCTTCAGTATCTAATCGCCGG 29

II. Methods of Predicting Susceptibility to Develop CholineDeficiency-Associated Health Effects

The presently disclosed subject matter provides for determining agenotype of a subject with respect to particular genes having a role incholine metabolism. Determining the genotype of the subject with regardto choline metabolism genes can elucidate susceptibility to developcholine deficiency-associated health effects in the subject. The presentsubject matter discloses that the PEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1,ABCB4, SLC44A1, CHKA, and CHKB genes encode for proteins that can each,and in combination with one another, play an important role in cholinemetabolism and individual sensitivity to choline deficiency. Thus,genotyping one or more of these genes can provide valuable informationrelated to choline deficiency sensitivity useful for predictingsusceptibility to develop choline deficiency-associated health effectsand even insights into effective therapies to treat cholinedeficiency-associated health effects and related conditions.

On the basis of the data disclosed herein and the related discussion,the presently disclosed subject matter provides methods of predictingsusceptibility of a subject, i.e. the predisposition of or risk of thesubject, to develop choline deficiency-associated health effects. Insome embodiments, the method comprises determining a genotype of thesubject with respect to at least one choline metabolism gene, such asfor example PEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1, ABCB4, SLC44A1, CHKA,CHKB, and combinations thereof; and comparing the genotype of thesubject with at least one reference genotype associated withsusceptibility to develop one or more choline deficiency-associatedhealth effects, whereby susceptibility of the subject to develop thecholine deficiency-associated health effects is predicted. In someembodiments, the reference genotype is selected from the group includingbut not limited to a PEMT genotype, a CHDH genotype, an MTHFD1 genotype,a BHMT genotype, an MTHFD1 genotype, an MTHFR genotype, a RFC1 genotype,an ABCB4 genotype, a SLC44A1 genotype, a CHKA genotype, a CHKB genotypeand combinations thereof.

“Reference genotype” as used herein refers to a previously determinedpattern of genetic variation associated with a particular phenotype,such as for example choline deficiency-associated health effects. Thereference genotype can be as minimal as the determination of a singlebase pair, as in determining one or more polymorphisms in the subject.Further, the reference genotype can comprise one or more haplotypes.Still further, the reference genotype can comprise one or morepolymorphisms exhibiting high linkage disequilibrium to at least onepolymorphism or haplotype. In some particular embodiments, the referencegenotype comprises one or more polymorphisms (e.g., SNPs) and/orhaplotypes of PEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1, ABCB4, SLC44A1,CHKA, CHKB, or combinations thereof determined to be associated withcholine deficiency-associated health effects. In some embodiments, thehaplotypes represent a particular collection of specific singlenucleotide polymorphisms.

In particular embodiments, the reference genotype is a human PEMTgenotype comprising a G-774C (rs12325817; SEQ ID NO: 1) polymorphism, ahuman CHDH genotype comprising a G432T (rs12676; SEQ ID NO:14)polymorphism, a human. CHDH genotype comprising a A318C (rs9001; SEQ IDNO:13) polymorphism, a human MTHFD1 genotype comprising a G1958A(rs2236225; SEQ ID NO:15 (note “G1958A” throughout the presentdisclosure references the polymorphism on the minus strand, whereas thers number and SEQ ID NO:15 disclose the complementary strand andreference the polymorphism as C/T)) polymorphism, or a combinationthereof. Further, in some embodiments, the determined genotype of thesubject with respect to PEMT comprises at least one copy of a PEMTrs12325817 C allele (i.e., a C is present at nucleotide −774 (non-codingregion) of at least one copy of the PEMT gene) and the subject ispredicted to be susceptible to develop one or more cholinedeficiency-associated health effects. In some embodiments, thedetermined genotype of the subject with respect to CHDH comprises atleast one copy of a CHDH rs12676 T allele (i.e., a T is present atnucleotide +432 (coding region) of at least one copy of the CHDH geneand the subject is predicted to be susceptible to develop one or morecholine deficiency-associated health effects. In some embodiments, thedetermined genotype of the subject with respect to CHDH comprises atleast one copy of a CHDH rs9001 C allele (Le., a C is present atnucleotide +318 (coding region) of at least one copy of the CHDH geneand the subject is predicted to be resistant to develop the one or morecholine deficiency-associated health effects. By “resistant” is meantthat the subject is less likely than the average over a population todevelop choline deficiency-associated health effects when consuming adiet low in choline over time. In some embodiments, the determinedgenotype of the subject with respect to MTHFD1 comprises at least onecopy of a MTHFD1 rs2236225 A allele (i.e., a A is present at nucleotide+1958 (coding region) of at least one copy of the MTHFD1 gene and thesubject is predicted to be susceptible to develop the one or morecholine deficiency-associated health effects.

In some embodiments of the methods of predicting susceptibility of asubject to develop one or more choline deficiency-associated healtheffects disclosed herein, determining the genotype of the subjectcomprises one or more of:

-   -   (i) identifying at least one polymorphism of the at least one        choline metabolism gene;    -   (ii) identifying at least one haplotype of the at least one        choline metabolism gene;    -   (iii) identifying at least one polymorphism unique to at least        one haplotype of the at least one choline metabolism gene;    -   (iv) identifying at least one polymorphism exhibiting high        linkage disequilibrium to at least one polymorphism unique to        the at least one choline metabolism gene; and    -   (v) identifying at least one polymorphism exhibiting high        linkage disequilibrium to the at least one choline metabolism        gene.

The determined genotype of the subject is then compared to one or morereference genotypes associated with susceptibility to develop one ormore choline deficiency-associated health effects and if the determinedgenotype matches the reference genotype, the subject is predicted to besusceptible to a particular degree (as compared to a population norm) todevelop one or more choline deficiency-associated health effects.

As indicated above, the determined genotype need not necessarily bedetermined based on a need to compare the determined genotype to thereference genotype in particular, but rather can be for example one ormore polymorphisms exhibiting high linkage disequilibrium to a PEMT,CHDH, BHMT, MTHFD1, MTHFR, RFC1, ABCB4, SLC44A1, CHKA, or CHKBpolymorphism or haplotype, or combinations thereof, which can be equallypredictive of susceptibility to develop one or more cholinedeficiency-associated health effects. For example, there are presentlymore than 98 known SNPs for PEMT (Saito et al. (2001)). Selecting one ormore of these SNPs, it is then determined, by art recognized techniques,if one or more of the known SNPs of PEMT exhibit high linkagedisequilibrium to one or more of the SNPs used to determine thereference genotypes of PEMT predictive of susceptibility to develop oneor more choline deficiency-associated health effects. Thus, after areview of the guidance provided herein, one of ordinary skill wouldappreciate that any one or more polymorphisms exhibiting high linkagedisequilibrium to a polymorphism or haplotype of the determined genotypewith regard to PEMT could likewise be effective as a substitute of oradditional component for the determined genotype and/or referencegenotype. Likewise, polymorphisms exhibiting high linkage disequilibriumto PEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1, ABCB4, SLC44A1, CHKA, and/orCHKB (i.e. haplotypes and/or polymorphisms) could be used to supplementor replace components of the determined genotype and/or referencegenotype.

As disclosed herein, it has been determined that certain polymorphismscorrelate particularly well as predictors of susceptibility to developcholine deficiency-associated health effects in female subjects andthese correlations can be utilized to determine appropriate treatmentoptions. Thus, in some embodiments, the subject is a female. Further, insome embodiments, the subject is a premenopausal female and thedetermined genotype of the subject comprises at least one copy of a PEMTrs12325817 C allele, at least one copy of a MTHFD1 rs2236225 A allele,or combinations thereof and the subject is therefore predicted to besusceptible to develop one or more choline deficiency-associated healtheffects. Further, in some embodiments, the premenopausal female subjectpredicted to be susceptible to develop one or more cholinedeficiency-associated health effects is predicted to be susceptible todevelop one or more congenital birth defects (e.g., neural tube defects)in a fetus carried by the subject as a result of choline deficiency inthe subject.

III. Methods of Predicting Biological Activity of Choline MetabolismPolypeptides

As disclosed herein, polymorphic differences in choline metabolism genescan be predictive of susceptibility to choline deficiency-associatedhealth effects by the subject carrying the polymorphism. In someinstances, the polymorphic difference can result in modulation inexpression levels of a polypeptide or modulation in biological activityof the expressed polypeptide as compared to a comparable polypeptideexpressed from a gene without the polymorphism. Thus, the polymorphicdifferences disclosed herein can be predictive of the biologicalactivity (including expression levels) of the expressed polypeptides.

As such, the presently disclosed subject matter provides methods ofpredicting biological activity of a choline metabolism polypeptide in asubject. In some embodiments, the methods comprise determining agenotype of the subject with respect to at least one choline metabolismgene, such as but not limited to PEMT, CHDH, BHMT, MTHFD1, MTHFR, RFC1,ABCB4, SLC44A1, CHKA, CHKB or combinations thereof and comparing thegenotype of the subject with at least one reference genotype associatedwith variability in biological activity of a choline metabolism gene,whereby biological activity of the proteins in the subject is predicted.Variability in biological activity can be either an increase or adecrease in activity (e.g., enzyme activity) of the polypeptidecomprising the predictive polymorphism as compared to a similarpolypeptide comprising the “normal” allele.

In some embodiments of the methods, determining the genotype of thesubject comprises one or more of:

-   -   (i) identifying at least one polymorphism of the at least one        choline metabolism gene;    -   (ii) identifying at least one haplotype of the at least one        choline metabolism gene;    -   (iii) identifying at least one polymorphism unique to at least        one haplotype of the at least one choline metabolism gene;    -   (iv) identifying at least one polymorphism exhibiting high        linkage disequilibrium to at least one polymorphism unique to        the at least one choline metabolism gene; and    -   (v) identifying at least one polymorphism exhibiting high        linkage disequilibrium to the at least one choline metabolism        gene.

In some embodiments the reference genotype is selected from the groupincluding but not limited to a PEMT genotype, a CHDH genotype, an MTHFD1genotype, a BHMT genotype, an MTHFD1 genotype, an MTHFR genotype, a RFC1genotype, an ABCB4 genotype, a SLC44A1 genotype, a CHKA genotype, and aCHKB genotype and combinations thereof. In particular embodiments, thereference genotype is a human PEMT genotype comprising a G-774C(rs12325817; SEQ ID NO: 1) polymorphism, a human CHDH genotypecomprising a G432T (rs12676; SEQ ID NO:14) polymorphism, a human CHDHgenotype comprising a A318C (rs9001; SEQ ID NO:13) polymorphism, a humanMTHFD1 genotype comprising a 01958A (rs2236225; SEQ ID NO:15), or acombination thereof. Each of these genotypes can be predictive of anactivity level of the particular choline metabolism polypeptide.

IV. Methods of Treatment

The genotyping methods for predicting susceptibility to develop by asubject choline deficiency-associated health effects disclosed hereinare applicable as well to the present methods of treating cholinedeficiency-associated health effects in a subject. Determining agenotype of a subject with regard to choline metabolism genes can beuseful in selecting a particular therapy for use in treating thesubject.

As such, in some embodiments of the presently disclosed subject mattermethods of treating choline deficiency-associated health effects in asubject are provided. In some embodiments, the methods comprisedetermining a genotype of the subject with respect to at least onecholine metabolism gene, such as but not limited to PEMT, CHDH, BHMT,MTHFD1, MTHFR, RFC1, ABCB4, SLC44A1, CHKA, CHKB, or combinationsthereof; comparing the determined genotype of the subject with at leastone reference genotype associated with susceptibility to develop one ormore choline deficiency-associated health effects, wherein the referencegenotype is at least one genotype of a choline metabolism gene; andadministering to the subject an effective amount of a choline supplementcomposition (e.g., a composition comprising choline, folate, orcombinations thereof, or any agent that can supplement cholinemetabolism, as would be apparent to one of ordinary skill in the artupon review of the instant disclosure), based on the determined genotypebeing associated with susceptibility to develop one or more cholinedeficiency-associated health effects.

“Treatment” and “treating” as used herein refer to any treatment of oneor more choline deficiency-associated health effects and includes: (i)preventing the health effect from occurring in a subject which may bepredisposed to the health effect, but has not yet been diagnosed ashaving it; (ii) inhibiting the health effect, i.e., arresting itsfurther development; or (iii) relieving the health effect, i.e., causingregression of clinical symptoms of the health effect.

In some embodiments of the methods, determining the genotype of thesubject comprises one or more of:

-   -   (i) identifying at least one polymorphism of the at least one        choline metabolism gene;    -   (ii) identifying at least one haplotype of the at least one        choline metabolism gene;    -   (iii) identifying at least one polymorphism unique to at least        one haplotype of the at least one choline metabolism gene;    -   (iv) identifying at least one polymorphism exhibiting high        linkage disequilibrium to at least one polymorphism unique to        the at least one choline metabolism gene; and    -   (v) identifying at least one polymorphism exhibiting high        linkage disequilibrium to the at least one choline metabolism        gene.

In some embodiments, the reference genotype is selected from the groupincluding but not limited to a PEMT genotype, a CHDH genotype, an MTHFD1genotype, a BHMT genotype, an MTHFD1 genotype, an MTHFR genotype, a RFC1genotype, an ABCB4 genotype, a SLC44A1 genotype, a CHKA genotype, a CHKBgenotype and combinations thereof. In particular embodiments, thereference genotype is a human PEMT genotype comprising a G-774C(rs12325817; SEQ ID NO: 1) polymorphism, a human CHDH genotypecomprising a G432T (rs12676; SEQ ID NO:14) polymorphism, a human CHDHgenotype comprising a A318C (rs9001; SEQ ID NO:13) polymorphism, a humanMTHFD1 genotype comprising a G1958A (rs2236225; SEQ ID NO:15), orcombinations thereof. Further, in some embodiments, the determinedgenotype of the subject with respect to PEMT comprises at least one copyof a PEMT rs12325817 C allele (i.e., a C is present at nucleotide −774(non-coding region) of at least one copy of the PEMT gene) and thesubject is administered the composition. In some embodiments, thedetermined genotype of the subject with respect to CHDH comprises atleast one copy of a CHDH rs12676 T allele (i.e., a T is present atnucleotide +432 (coding region) of at least one copy of the CHDH geneand the subject is administered the composition. In some embodiments,the determined genotype of the subject with respect to CHDH comprises atleast one copy of a CHDH rs9001 C allele (i.e., a C is present atnucleotide +318 (coding region) of at least one copy of the CHDH geneand the subject is not administered the composition. In someembodiments, the determined genotype of the subject with respect toMTHFD1 comprises at least one copy of a MTHFD1 rs2236225 A allele (i.e.,a A is present at nucleotide +1958 (coding region) of at least one copyof the MTHFD1 gene and the subject is administered the composition.

In some embodiments, the subject is a female. Further, in someembodiments, the subject is a premenopausal female and the determinedgenotype of the subject comprises at least one copy of a PEMT rs12325817C allele, at least one copy of a MTHFD1 rs2236225 A allele, orcombinations thereof and the subject is predicted to be susceptible todevelop one or more choline deficiency-associated health effects and istherefore administered the therapeutic composition. Further, in someembodiments, the premenopausal female subject predicted to besusceptible to develop one or more choline deficiency-associated healtheffects is predicted to be susceptible to develop one or more congenitalbirth defects (e.g., neural tube defects) in a fetus carried by thesubject as a result of choline deficiency in the subject and istherefore administered the therapeutic composition.

IV.A. Formulations

A therapeutic composition as described herein preferably comprises acomposition that includes a pharmaceutically acceptable carrier.Suitable formulations include aqueous and non-aqueous sterile injectionsolutions that can contain antioxidants, buffers, bacteriostats,bactericidal antibiotics and solutes that render the formulationisotonic with the bodily fluids of the intended recipient; and aqueousand non-aqueous sterile suspensions, which can include suspending agentsand thickening agents.

The compositions used, in the methods can take such forms assuspensions, solutions or emulsions in oily or aqueous vehicles, and cancontain formulatory agents such as suspending, stabilizing and/ordispersing agents. Alternatively, the active ingredient can be in powderform for constitution with a suitable vehicle, e.g., sterilepyrogen-free water, before use.

The formulations can be presented in unit-dose or multi-dose containers,for example sealed ampoules and vials, and can be stored in a frozen orfreeze-dried (lyophilized) condition requiring only the addition ofsterile liquid carrier immediately prior to use.

For oral administration, the compositions can take the form of, forexample, tablets or capsules prepared by a conventional technique withpharmaceutically acceptable excipients such as binding agents (e.g.,pregelatinized maize starch, polyvinylpyrrolidone or hydroxypropylmethylcellulose); fillers (e.g., lactose, microcrystalline cellulose orcalcium hydrogen phosphate); lubricants (e.g., magnesium stearate, talcor silica); disintegrants (e.g., potato starch or sodium starchglycolate); or wetting agents (e.g., sodium lauryl sulphate). Thetablets can be coated by methods known in the art.

Liquid preparations for oral administration can take the form of, forexample, solutions, syrups or suspensions, or they can be presented as adry product for constitution with water or other suitable vehicle beforeuse. Such liquid preparations can be prepared by conventional techniqueswith pharmaceutically acceptable additives such as suspending agents(e.g., sorbitol syrup, cellulose derivatives or hydrogenated ediblefats); emulsifying agents (e.g. lecithin or acacia); non-aqueousvehicles (e.g., almond oil, oily esters, ethyl alcohol or fractionatedvegetable oils); and preservatives (e.g., methyl orpropyl-p-hydroxybenzoates or sorbic acid). The preparations can alsocontain buffer salts, flavoring, coloring and sweetening agents asappropriate. Preparations for oral administration can be suitablyformulated to give controlled release of the active compound. For buccaladministration the compositions can take the form of tablets or lozengesformulated in conventional manner.

The compounds can also be formulated as a preparation for implantationor injection. Thus, for example, the compounds can be formulated withsuitable polymeric or hydrophobic materials (e.g., as an emulsion in anacceptable oil) or ion exchange resins, or as sparingly solublederivatives (e.g., as a sparingly soluble salt).

The compounds can also be formulated in rectal compositions (e.g.,suppositories or retention enemas containing conventional suppositorybases such as cocoa butter or other glycerides), creams or lotions, ortransdermal patches.

IV.B. Doses

The term “effective amount” is used herein to refer to an amount of thetherapeutic composition (e.g., a composition comprising choline, folate,or combinations thereof) sufficient to produce a measurable biologicalresponse (e.g., a reduction in one or more choline deficiency-associatedhealth effects). Actual dosage levels of active ingredients in atherapeutic composition of the presently disclosed subject matter can bevaried so as to administer an amount of the active compound(s) that iseffective to achieve the desired therapeutic response for a particularsubject and/or application. The selected dosage level will depend upon avariety of factors including the activity of the therapeuticcomposition, formulation, the route of administration, combination withother drugs or treatments, severity of the condition being treated, andthe physical condition and prior medical history of the subject beingtreated. Preferably, a minimal dose is administered, and dose isescalated in the absence of dose-limiting toxicity to a minimallyeffective amount. Determination and adjustment of a therapeuticallyeffective dose, as well as evaluation of when and how to make suchadjustments, are known to those of ordinary skill in the art ofmedicine. Minimal daily recommended dosages of choline (e.g., about400-600 mg/day) and/or folate (e.g., about 300-500 μg/day) can beadministered as an initial baseline to subjects being treated and slowlyraised as necessary to maximum safe dosages.

For additional guidance regarding formulation and dose, see U.S. Pat.Nos. 5,326,902; 5,234,933; PCT International Publication No. WO93/25521; Berkow et al. (1997); Goodman et al. (1996); Ebadi (1998);Katzunq (2001); Remington et al. (1975); Speight et al. (1997); and Duchet al. (1998).

IV.C. Routes of Administration

Suitable methods for administering to a subject a composition inaccordance with the methods of the presently disclosed subject matterinclude but are not limited to systemic administration, parenteraladministration (including intravascular, intramuscular, intraarterialadministration), oral delivery, buccal delivery, subcutaneousadministration, inhalation, intratracheal installation, surgicalimplantation, transdermal delivery, local injection, and hyper-velocityinjection/bombardment.

The particular mode of drug administration used in accordance with themethods of the presently disclosed subject matter depends on variousfactors, including but not limited to the vector and/or drug carrieremployed, the severity of the condition to be treated, and mechanismsfor metabolism or removal of the drug following administration.

V. Subjects

A “subject” as the term is used herein generally refers to an animal. Insome embodiments, an animal subject is a vertebrate subject. Further, insome embodiments, a vertebrate is warm-blooded and a representativewarm-blooded vertebrate is a mammal. A representative mammal is mostpreferably a human. However, as used herein, the term “subject” includesboth human and animal subjects. Thus, veterinary therapeutic uses areprovided in accordance with the presently disclosed subject matter.

As such, the presently disclosed subject matter provides for theanalysis and treatment of mammals such as humans, as well as thosemammals of importance due to being endangered, such as Siberian tigers;of economic importance, such as animals raised on farms for consumptionby humans; and/or animals of social importance to humans, such asanimals kept as pets or in zoos. Examples of such animals include butare not limited to: carnivores such as cats and dogs; swine, includingpigs, hogs, and wild boars; ruminants and/or ungulates such as cattle,oxen, sheep, giraffes, deer, goats, bison, and camels; and horses. A“subject” as the term is used herein can further include birds, such asfor example those kinds of birds that are endangered and/or kept inzoos, as well as fowl, and more particularly domesticated fowl, i.e.,poultry, such as turkeys, chickens, ducks, geese, guinea fowl, and thelike, as they are also of economical importance to humans. Thus,“subject” further includes livestock, including, but not limited to,domesticated swine, ruminants, ungulates, horses (including racehorses), poultry, and the like.

Certain subjects are particularly vulnerable to choline deficiencies. Inparticular, subjects receiving an insufficient dietary intake of cholinecan be at risk of suffering from choline deficiency-associated healtheffects. For example, subjects receiving substantially all nutritionalsustenance parenterally (e.g., via intravenous line) can be vulnerableto dietary choline deficiencies, which can result in for example liverdysfunction. Likewise, due to the increased nutrient demands on a motherby a fetus in utero, pregnant subjects can be vulnerable to cholinedeficiencies, which can result in choline deficiency-associated healtheffects in the pregnant subject and/or the fetus. As such, although notlimited to these populations particular susceptible to dietary cholinedeficiencies, application of the presently disclosed subject mattermethods to these subjects can provide significant benefits.

EXAMPLES

The following Examples have been included to illustrate modes of thepresently disclosed subject matter. In light of the present disclosureand the general level of skill in the art, those of skill willappreciate that the following Examples are intended to be exemplary onlyand that numerous changes, modifications, and alterations can beemployed without departing from the scope of the presently disclosedsubject matter.

Materials and Methods for Examples 1-3

Subjects. Healthy adults were recruited by advertising. Both males(n=31) and females (n=31) were included, with ages ranging from 18 to 70years. Inclusion was contingent on age-typical good state of health asdetermined by physical examination and standard clinical laboratorytests. Of the originally recruited 62 subjects, 58 completed at leastthe initial baseline phase and the depletion phase. Of these 58, 1subject was excluded because of a 9-kg weight loss during the study, and3 subjects were excluded because they did not comply with dietrestrictions, leaving 54 subjects included in all analyses. Subjectcharacteristics were as follows: 28 women and 26 men; 34 Caucasians, 14African-Americans, 3 Asians, and 3 of other ethnicity; mean age was38.7+/−15.4 (SD) years; mean body mass index was 25.0+/−3.7 kg/m². Theethnicity of the participants reflects the local populationcharacteristics of the Raleigh-Durham-Chapel Hill area of NorthCarolina, U.S.A. The criteria for subject selection and all details ofthe clinical protocol were approved by the institutional review board ofthe University of North Carolina at Chapel Hill.

Clinical Studies. The participants stayed at the University of NorthCarolina at Chapel Hill General Clinical Research Center, Chapel Hill,N.C., U.S.A. for the entire duration of the study and could leave onlyfor brief periods under the direct supervision of study staff. All foodswere prepared in-house to protocol specifications (Busby et al. (2004)).Total food intake was adjusted to be isocaloric and to provide adequateintake levels of macro- and micronutrients. Individual energyrequirements were estimated by using the Harris-Benedict equation, andindividual adjustments were made during the first week on the basaldiet, if necessary, to achieve participants' satiety. Once individualneeds had been determined, daily energy intakes were kept at a constantlevel, ranging between 35 and 45 kcal/kg of body weight. The diets,which provided 0.8 g/kg high biologic value protein, with 30% energycoming from fat and the remaining energy from carbohydrate, met orexceeded the estimated average requirement for methionine plus cysteineand the recommended dietary allowances for vitamin B12 and all othervitamins except folic acid (diets contained 100 pg/day folate, seebelow). During the initial 10 days (baseline), the participants consumednormal foods containing 550 mg of choline per 70 kg of body weight perday, which approximates the current adequate intake level (550 mg/dayfor men and 425 mg/day for women) and 400 μg of folic acid per day as asupplement (General Nutrition Center, Pittsburgh, Pa., U.S.A.). Theactual choline content of a sampling of duplicate portions was assayedby our laboratory (Zeisel et al. (2003)).

Subjects were then switched to a choline depletion diet containing <50mg of choline per 70 kg of body weight per day by eliminatingcholine-rich foods, as confirmed by analysis of duplicate food portions(Ubbink et al. (1991); Davis et al. (2005)). Details of dietformulations were previously published (Busby et al. (2004)). Table 2provides an exemplary research diet menu including actual amounts offood provided for a 2500 kilocalorie diet containing varying amounts ofcholine. Furthermore, participants were randomly assigned to receiveeither placebo or 400 μg of folic acid per day as a supplement inaddition to the amount of folate consumed with food (100 μg/day). Dietswere well tolerated.

TABLE 2 Choline Deficient Repletion Diets* Diet 25% 50% 75% 100% FoodItem Wt (g) Wt (g) Wt (g) Wt (g) Wt (g) BREAKFAST Raw Egg White, Fresh100 50 50 50 50 Wheat Starch/Lecithin 20 20 40 65 85 Bread** Margarine 010 10 10 10 Soy Protein Beverage 300 240 240 0 0 (Recipe II) Coffee,Decaf Instant 2 2 2 2 2 Cream Substitute- 2 2 2 2 2 Powder Coca ColaClassic, 237 350 350 300 300 Caffeine-Free AM SNACK Coca Cola Classic237 350 350 300 300 LUNCH Cheese 20 20 20 20 20 Wheat Starch/Lecithin 2525 40 60 85 Bread** Margarine 15 15 15 15 10 Applesauce, 100 100 100 100100 unsweetened Soy Protein Beverage 300 240 240 250 250 (Recipe II)Coca Cola Classic, 474 350 350 300 300 Caffeine-Free PM SNACK Coca ColaClassic 237 350 350 300 300 DINNER Roasted Turkey 20 20 20 20 20 Breast,no skin French Fries, 30 30 30 30 30 from frozen Wheat Starch/Lecithin 0240 35 60 85 Bread** Margarine 0 0 0 15 15 Soy Protein Beverage 300 350240 250 250 (Recipe II) Coca Cola Classic 237 0 350 300 300 HS SNACKTortilla Chips, Plain 12 12 12 12 12 Coca Cola Classic, 237 350 350 300250 Caffeine-Free

Periodic determinations of urinary choline and betaine concentrationswere used to confirm compliance with the dietary restrictions. Subjectsremained on this depletion diet until they developed signs of organdysfunction associated with choline deficiency, or for 42 days if theydid not. Human subjects were deemed to have signs of organ dysfunctionassociated with choline deficiency if they had more than a 5-foldincrease of serum creatine kinase (CK) activity while on the cholinedepletion diet and if this increased CK resolved when they were returnedto the repletion diet (da Costa et al. (2004)), or if they had anincrease of liver fat content by 28% or more while on the cholinedepletion diet and if this increased liver fat resolved when they werereturned to the repletion or ad libitum diet (da Costa et al. (2005)).After the depletion period, subjects were repleted by graduallyincreasing choline intake and were maintained at a final level of >550mg of choline per day for at least 3 days.

Change in liver fat content was estimated by MRI with a clinical MRsystem (VISION® 41.5-T, Siemens, Iselin, N.J., U.S.A.) using a modified“In and Out of Phase” procedure (da Costa et al. (2005); Fishbein et al.(1997)). This approach utilizes the differences in transversemagnetization intensity after an ultra brief time interval [fastlow-angle shot (FLASH); echo time (TE)=2.2 msec and 4.5 msec, with aflip angle of 80°, and relaxation time (TR)_(—)140 msec]. Processing ofsuccessive FLASH MRI images with software from Siemens Medical Solutions(Malvern, Pa., U.S.A.) was used to estimate fat content. Organ contentwas derived from measurements across five liver slices per subject andstandardized by relating the results to the similarly measured fatcontent of spleen. It was assumed that spleen signal would be largelyinvariant and used this value to calculate the outcome variableliver-to-spleen fat ratio.

Fasting blood samples were taken every 3-4 days throughout the study,and in particular, after 10 days on the 550 mg/day choline diet(baseline), at the end of the low-choline diet (depletion phase), andafter consuming a repletion diet with 137-550 mg/day choline (repletionphase). The metabolic response to an oral challenge with 100 mgL-methionine/kg was determined initially and after depletion. Blood forhomocysteine, SAM, and S-adenosylhomocysteine (SAH) measurements wasobtained before and 4 hours after methionine ingestion (da Costa et al.(2005)).

Laboratory Analyses. Plasma folate concentrations in fasted samples weremeasured by using a microbiological assay (Home & Patterson (1988)).Serum was analyzed by using a dry-slide colorimetric method for CKactivity by the McClendon Clinical Laboratories at University of NorthCarolina Hospitals, which is both Clinical Laboratory Improvement Act(CLIA)- and College of American Pathologists (CAP)-accredited. Totalplasma homocysteine concentration was measured in fasted samples byusing a HPLC method (da Costa et al. (2005); Ubbink et al. (1991)). SAMand SAH levels in plasma were measured by HPLC with fluorescencedetection after conversion into their fluorescent isoindoles (Davis etal. (2005)).

Genotyping. Genomic DNA was prepared according to manufacturer'sinstructions from peripheral blood with a commercial extraction kit(PUREGENE®, Gentra Systems, Minneapolis, Minn., U.S.A.) and diluted to astandard concentration of 1 μg/ml. The polymorphic sites of MTHFR(MTHFR-C677T and -A1298C), cytosolic C-1-THF synthase (MTHFD1-G1958A),and reduced folate carrier 1 (RFC1-G80A) were studied (see FIG. 2). Thetargeted DNA sequences were amplified by multiplex PCR, purified, andthen analyzed with matrix-assisted laser desorption/ionizationtime-of-flight mass spectrometry (Meyer et al. (2004)). For allsubjects, duplicate samples were genotyped. In the few instances ofamplification failure, new DNA was prepared from backup blood samples.

Statistical Analysis. Genotype-related differences in dichotomousoutcomes were calculated with two-sided Fisher's exact probability testto determine statistical significance (GraphPad, San Diego, Calif.,U.S.A.). Odds ratios for depletion by presence vs. absence of thepredominant alleles were calculated as the odds to deplete for subjectswith the allele divided by odds for subjects without the allele (Bland &Altman (2000)). Statistical significance of odds ratios was againcalculated using two-sided Fisher's exact probability test. Thestatistical significance of group differences for continuous variableswas assessed with Student's t test, and differences between subjects ondifferent diets were assessed by using pair t tests. A two sample t testbased on the differences between homocysteine concentrations in subjectson the two diets was used to compare the clinically depleted andnot-depleted groups (GraphPad).

Example 1 Genetic Variation and Folate Status

The distribution of the polymorphic variants of MTHFR and cytosolicMTHFD1 (Table 3) largely agreed with that of larger North Europeanpopulations that were analyzed previously with the same genotypingmethodology. Within this study group, however, fewer African-Americansthan Caucasians had the variant allele MTHFD1 1958A (allele frequency0.18 vs. 0.50). The RFC1 80G allele was slightly underrepresented inthese subjects (0.47 vs. 0.58), but this was considered the referenceallele, nonetheless. The difference is mostly attributable to thepresence of many non-Caucasians in our regionally representativepopulation sample.

Twenty-six participants were assigned to receive placebo, and 28subjects received an additional 400 μg of folic acid per day as asupplement. Average serum folate concentration at the end of thedepletion phase was lower in subjects with the lower folate intake(22.1+/−1.3 nmol_liter vs. 28.3+/−1.2 nmol/liter; P<0.01 by Student's ttest). None of the investigated polymorphisms had a statisticallysignificant effect on serum folate concentrations at any time point.

TABLE 3 % subjects with signs of choline Odds ratio and PolymorphismGenotype (n) deficiency P 95% CI MTHFR 677 CC (28) 61 0.63 CC vs. CT/TTCT (22) 73 Odds ratio, 1.76 TT (4) 75 95% CI, 0.56-5.6 MTHFR 1298 AA(28) 64 0.90 AA vs AC/CC AC (22) 68 Odds ratio, 1.25 CC (4) 75 95% CI,0.40-3.9 MTHFD1 1958 GG (20) 40 0.007 GG vs GA/AA GA (28) 82 Odds ratio,7.0 AA (6) 83 95% CI, 2.0-25 RFC1 80 AA (19) 56 0.59 AA vs AG/GG AG (20)70 Odds ratio, 1.82 GG (15) 73 95% CI, 0.56-5.9

Example 2 Signs of Organ Dysfunction Associated with Choline Deficiency

Twelve subjects responded to the low-choline diet with an increase inserum CK activity, all but one within a month on the depletion diet. Asignificant increase in liver fat content was observed in another 24participants, usually within a month on the depletion diet. In six ofthese participants, however, it took up to 42 days to accumulate theadditional 28% or more of liver fat. Eighteen subjects did not showsigns of organ dysfunction in response to the low-choline diet. Dailysupplementation with folic acid did little to affect the likelihood ofdeveloping signs of choline deficiency [odds ratio, absence overpresence of signs of choline deficiency in subjects with supplementationvs. without supplementation 0.8, 95% confidence interval (CI),0.26-2.5].

Example 3 Methionine Metabolism

Homocysteine concentrations during both baseline and choline-depletionconditions were measured in 54 subjects, and methionine load tests werecompleted in 52 of these participants at the end of the baseline anddepletion diet phases. Homocysteine concentration increased by 19% withthe low-choline regime (P<0.001, paired t test). Supplementation with400 μg/day folic acid blunted this increase, compared with placebo (15%vs. 23% increase, P<0.05, Student's t test). However, there was nosignificant interaction between fasting plasma homocysteineconcentration and clinical status (P=0.113, Student's t test), becausethere was a similar increase of this measure in subjects judged to beclinically depleted (by 1.4 μmol/liter; 95% CI, 1.1-1.7) as in subjectswithout clinical signs of choline deficiency (0.9 μmol/liter; 95% CI,0.5-1.4). None of the polymorphic variants had a statisticallysignificant influence on plasma homocysteine concentrations, at eitherbaseline or depletion. The expected rise of plasma homocysteineconcentration after methionine loading was observed on both diets. Therise in homocysteine concentration in response to the methioninechallenge in subjects eating the 550-mg choline diet was significantlyless in subjects without the RFC1 80G allele than in the carriers ofthis allele (P=0.02, Student's t test). None of the other polymorphicvariations were predictive for the metabolic response to methionine orthe change of this response with choline depletion.

The rise in plasma homocysteine concentration after a methionine loadwas greater in individuals developing signs of choline deficiency wheningesting a low-choline diet than in those that did not. In thisExample, after a methionine load at the end of the depletion phase,plasma homocysteine concentrations in the group with signs of cholinedeficiency rose 6.9 μmol/liter above that which was previously observedafter a methionine load on the 550-mg choline diet (95% CI, 4.4-9.3,P_(—)0.0001). For subjects without signs of deficiency, plasmahomocysteine did not increase significantly after the same methionineload (1.6 μmol/liter; 95% CI, −1.7-4.9, P=0.318).

SAM and SAH concentrations were assessed in 26 individuals with MTHFD11958GA/AA genotype and in 15 individuals with MTHFD1 1958GG genotype.Concentrations did not change significantly upon switching from baselineto a low-choline diet. On both the baseline and the low-choline diets,SAM and SAH concentrations increased greatly after oral methionine load,as expected. The post-loading concentration of SAH increased from28.8+/−12.8 nmol/liter on the baseline diet to 34.7+/−12.8 nmol/liter onthe low-choline diet (P<0.05). No statistically significant change ofpost-loading SAM concentrations in response to the low-choline diet wasobserved. Although SAM concentrations at depletion did not differsignificantly between MTHFD1 1958 genotype groups, SAH concentrationswere significantly lower in participants with the GG genotype than inthose with the GA and AA genotypes, both with and without methionineloading (FIG. 3). The same pattern of genotype-SAH concentration wasobserved while subjects were on the baseline diet, but the contrasts didnot reach statistical significance.

Among the examined polymorphisms, the MTHFD1 G1958A variant was the bestpredictor of susceptibility to choline depletion (Table 3). In light ofthe subject numbers in several of the cells, the carriers of what areusually the minor alleles were grouped together for calculating oddsratios. Again, the MTHFD1 polymorphism was the only one of the fourvariants tested with a distinct impact on risk of developing clinicalsigns of choline deficiency. A higher percentage of the 34 carriers ofthe 1958A allele showed signs of choline deficiency in response to thelow-choline diet (odds ratio, 7.0; two-sided, P=0.0025; Table 4). Thisgenotypic difference was attributable to the fact that none of the youngwomen with MTHFD1 1958GG genotype showed deficiency signs, whereas sevenof the eight young women carriers of the GA or AA genotypes did so. Thecorresponding differences were not seen in men (odds ratio, 3.0; P=0.33)and postmenopausal women (odds ratio, 1.0; P=0.99). However, becauseonly four postmenopausal women had the MTHFD1 1958-GG genotype, thepower to detect an odds ratio of 7.0 (the average for all subjects) atthe usual level of significance was only 0.13. With the eight malecarriers of the GG genotype, the corresponding statistical power alsowas low. Thus, the study could have been underpowered for the detectionof an effect smaller than the one observed in the young women it ispossible effects measured could be significant given a study with alarger population.

In regard to folate supplementation, the MTHFD1 1958A allele-relateddifference in susceptibility to developing organ dysfunction when eatinga low-choline diet was greatest in the group getting folate only fromthe diet (no supplement; odds ratio, 35; two-sided, P=0.001; Table 4)and was much smaller and statistically not significant in thefolate-supplemented group (odds ratio, 2.5; two-sided, P=0.41; Table 4).

TABLE 4 % subjects with signs of choline Odds ratio and Group Genotype(n) deficiency P 95% CI Premenopausal women GG (8) 0 Odds ratio, 85*GA/AA (8) 88 0.000 95% CI, 3-2418 Postmenopausal women GG (4) 75 Oddsratio, 1.0 GA/AA (8) 75 0.99 95% CI, 0.06-16 Men GG (8) 63 Odds ratio,3.0 GA/AA (18) 83 0.33 95% CI, 0.45-20 All subjects GG (20) 40 Oddsratio, 7.0 GA/AA (34) 82 0.007 95% CI, 2.0-25 Diet folate only GG (10)30 Odds ratio, 35 GA/AA (16) 94 0.00 95% CI, 3.0-39 Diet folate plusfolic acid GG (10) 50 Odds ratio, 2.6 supplement (400 μg/day) GA/AA (18)72 0.41 95% CI, 0.52-13

Discussion of Examples 1-3

In the investigation of healthy subjects in Examples 1-3, more than halfof the participants developed signs of organ dysfunction when consuminglow-choline diets. Examples 1-3 focus on the impact of genetic variantsof folate metabolism on susceptibility to clinical choline deficiency.One significant finding was the strong association of the MTHFD1 G1958Apolymorphism with susceptibility to developing signs of organdysfunction associated with choline deficiency. Presence of the MTHFD11958A allele made it much more likely that subjects developed signs ofcholine deficiency.

Choline-deficient individuals were found to have impaired capacity tohandle a methionine load, developing elevated plasma SAH andhomocysteine concentrations. This finding highlights the importance ofalternative folate-mediated pathways for homocysteine remethylation. Theobservation of higher SAH concentrations in carriers of the MTHFD1 1958Aallele (rs2236225; SEQ ID NO:15), compared with non-carriers, isparticularly informative, because accumulation of this metabolite hasbeen found to be a more sensitive indicator of disturbed methionineregeneration than is elevated homocysteine concentration (Kerins et al.(2001)). SAH is a potent inhibitor of phosphatidylethanolaminemethyltransferase, which catalyzes the endogenous formation of cholinemoiety in liver (Vance et al. (1997)).

Without wishing to be bound by any particular theory,phosphatidylethanolamine methyltransferase activity is increased byestrogen (Drouva et al. (1986)), and this mechanism could explain why itwas observed that premenopausal women were relatively resistant todeveloping signs of organ dysfunction when fed a low-choline diet,compared with men. It is in these premenopausal women that the mostsignificant effect of the MTHFD1 1958A SNP on susceptibility todeveloping signs of choline deficiency was observed (Table 4). Again,without wishing to be bound by theory, this suggests that this SNPrestricts methyl-group availability enough so that SAM availability forthe phosphatidylethanolamine methyltransferase-catalyzed formation ofcholine moiety becomes limiting, thereby eliminating this protectivemechanism for females. The SAH data provided in these Examples (FIG. 3)support this hypothesis. Alternatively, it is possible that men andpostmenopausal women are already so susceptible to choline deficiency(80% show signs of organ dysfunction on a low-choline diet) that afurther increase in susceptibility cannot be appreciated, given thesmall incremental effect size. In premenopausal women, in contrast,where 60% of the population was resistant to choline deficiency, therewas sufficient margin for detecting an increase in susceptibilityassociated with the MTHFD1 1958A SNP.

Under standard conditions, serine provides the bulk of one-carbon groups(Davis et al. (2004)). Cytosolic serine hydromethyltransferase (EC2.1.2.1) transfers a one-carbon unit from serine to THF, and theresulting 5,10-methylene-THF can then be reduced by MTHFR to5-methyl-THF. An alternative source for the one-carbon unit is derivedfrom formate through mitochondrial or cytosolic reactions that can belinked to free folate by formyl-THF synthetase (EC 6.3.4.3) and generate10-formyl-THF in an ATP-dependent reaction. This distinct reaction isonly one of three that are catalyzed by the cytosolic enzyme C-1-THFsynthase complex (all encoded by the MTHFD1 gene sequence). Twoadditional reactions, mediated by methylene-THF dehydrogenase (EC1.5.1.5) and methenyl-THF cyclohydrolase (EC 3.5.4.9), can then convert10-formyl-THF to 5,10-methylene-THF (FIG. 2). Although the formation of5-methyl-THF is practically irreversible in vivo, the interconversion of5,10-methylene-THF and 10-formyl-THF is closer to equilibrium (Home, D.W. (2003)). Thus, 5,10-methylene-THF can be directed either towardhomocysteine remethylation or away from it. Both purine synthesis andoxidative release of carbon dioxide and THF by 10-formyl-THFdehydrogenase (EC 1.5.1.6) draw on the 10-formyl-THF pool. Theirreversible and nonproductive dissipation of an excess in transferableone-carbon units is likely to be a significant regulatory factor,because the intrahepatic concentration of 10-formyl-THF exceeds thehalf-maximal equilibrium constant Km of 10-formyl-THF dehydrogenase(Gregory et al. (2000)). The 10-formyl-THF synthase activity of C-1-THFsynthase, on the other hand, can add to the 5,10-methylene-THF pool bylinking formate to free folate.

The G-to-A transition mutation at nucleotide 1958 in MTHFD1 causes anarginine to glutamine substitution in the protein region responsible for10-formyl-THF dehydrogenase, which is far removed from the regionproviding for the methenyl-THF cyclohydrolase and methylene-THFdehydrogenase activities. Without wishing to be bound by theory, theMTHFD1 G1958A polymorphism could thus affect the delicately balancedflux between 5,10-methylene-THF and 10-formyl-THF and thereby influencethe availability of 5-methyl-THF for homocysteine remethylation. Thepattern of decreased SAM:SAH ratios among individuals with an MTHFD11958A allele appears to be consistent with the view that theirone-carbon flux slightly tilts away from 5-methyl-THF formation. Thefinding of increased susceptibility to developing signs of cholinedeficiency coinciding with evidence of impaired 5-methyl-THFavailability (increased SAH concentration) in carriers of an MTHFD11958A allele makes it less likely that the association is due to justrandom chance. If a nearby gene locus in strong linkage disequilibriumwith the MTHFD1 1958A were ultimately responsible for increasedsusceptibility to choline deficiency, this locus also would have toexplain the observed shift in methyl-group metabolism.

It is of particular interest that the gene-variant effect can beovercome if subjects are supplemented with folic acid. It might seemsurprising that the development of choline deficiency signs was stronglyfavored by the presence of the MTHFD1 1958A allele but not bypolymorphic variants of MTHFR or RFC1. A partial explanation could beprovided by a recent investigation of folate-dependent homocysteineremethylation in young women (Davis et al. (2005)). This study foundthat the MTHFR 677TT genotype had little detectable effect onremethylation flux. In comparison, the MTHFD1 1958A polymorphism, whichhas not been extensively investigated until the present study, could bea more potent determinant of the rate at which one-carbon units becomeavailable for methyl-group transfer reactions, such as the synthesis ofphosphatidylcholine from phosphatidylethanolamine.

Observations on genetically linked susceptibility to choline deficiencyare important because they can assist refinement of recommendations fordietary choline intake by taking into account the needs of sizeablepopulation groups with greater-than-average vulnerability to low cholineor folate intake. There also is a potential relevance for the preventionof neural tube defects. One of the great successes of nutrition sciencehas been the identification of the role that folate plays in normalneural tube closure; adequate dietary folate intake by mothers duringpregnancy can prevent >50% of neural tube defects in babies (Shaw et al.(1995)).

As disclosed herein, choline and folate metabolism are highlyinterrelated (see FIG. 2). Inhibition of choline uptake and metabolismwas associated with the development of neural tube defects in mice(Fisher et al. (2001); Fisher et al. (2002)). Recent evidence suggeststhat availability of choline also might impact the risk of neural tubedefects in humans: A retrospective case-control study (400 cases and 400controls) of periconceptional dietary intakes of choline in women foundthat women in the lowest quartile for daily choline intake had 4× therisk of having a baby with a neural tube defect than did women in thehighest quartile for intake (Shaw et al. (2004)). The presentlydisclosed subject matter indicates the benefit of evaluatinginteractions among dietary choline intake, folate intake, and MTHFD1polymorphisms.

Materials and Methods for Example 4

Study design. Healthy males (n=31) and females (n=35) were recruited byadvertising. They ranged in age from 18 to 70 years and had body massindices between 19 and 33. Informed consent was obtained from allparticipants after the nature and possible consequences of the studywere explained; the criteria for subject selection and all details ofthe clinical protocol were approved by the Institutional Review Board ofthe University of North Carolina at Chapel Hill (UNC-CH). The ethnicityof the participants was Caucasians (65%), African-Americans (25%),Asians (5%), Native Americans (3%), and other heritages (2%) reflectingthe local population characteristics of the Raleigh-Durham-Chapel Hillarea. Inclusion was contingent on age-typical good state of health asdetermined by physical examination and standard clinical laboratorytests. Of the originally recruited 66 subjects, 61 completed at leastthe initial phase and the depletion phase. Of these 61, 1 subject wasexcluded due to 9 kg wt loss during the study and 3 subjects wereexcluded because they did not comply with diet restrictions, leaving 57subjects included in analyses.

The participants were admitted to the UNC-CH General Clinical ResearchCenter for the duration of the study and could leave only for briefperiods under the supervision of study staff. The diets, which werecomposed of 0.8 g/kg high biological value protein, with 30% kcal comingfrom fat and the remaining kcal from carbohydrate, were preparedin-house to protocol specifications and are described in detail inanother publication (Busby et al. (2004)). Total food intake wasadjusted to be isocaloric and provided adequate intakes of macro- andmicronutrients. Initially, all participants received a diet of normalfoods containing 550 mg choline/70 kg body wt/day. This diet contained50 mg betaine/70 kg body wt/day. After 10 days (FIG. 4) the cholinecontent of the diet was reduced to <50 mg/day (with 6 mg betaine/70 kgbody wt/day), as confirmed by analysis of duplicate food portions(Zeisel et al. (2003); Koc et al. (2002)). Periodic determinations ofurinary choline and betaine concentrations (Koc et al. (2002)) were usedto confirm compliance with the dietary restrictions. Subjects remainedon this depletion diet until they developed organ dysfunction associatedwith choline deficiency, or for 42 days if they did not. Subjects weredeemed to have organ dysfunction associated with choline deficiency ifthey had a >5-fold increase of serum creatine phosphokinase (CPK)activity (da Costa et al. (2004)) or if they had an increase in liverfat content by >28% while on the choline depletion diet, and if thisincreased CPK or increased liver fat resolved when choline was returnedto the diet. After the depletion study, subjects were repleted bygradually increasing their choline intake to a final concentrationof >550 mg per day and maintaining that concentration for at least 3days. All 57 (54 for PEMT rs7946 (SEQ ID NO:3) and BHMT rs3733890 (SEQID NO:26) individuals were genotyped as described below for thefollowing SNPs (the positions of the PEMT SNPs were enumerated withpromoter B (Shields et al. (2001)) as a reference): PEMT rs7946 (G5465A;SEQ ID NO:3), rs2278952 (C164T; SEQ ID NO:2), rs12325817 (G-744C; SEQ IDNO:1) and for two other SNPs of PEMT at position C-314T of the PEMTpromoter, and C29G of exon 2, which adjoins the promoter; BHMT rs3733890(SEQ ID NO:26); CHDH rs9001 (SEQ ID NO:13), and rs12676 (SEQ ID NO:14)(Table 5). Plasma collected at the end of the adequate choline intakephase and depletion phase were analyzed for concentrations of betaine,choline, and phosphatidylcholine (Koc et al. (2002)).

Liver fat measurement. Liver fat was measured at the end of the 550 mgcholine diet and at 21 and 42 days on the choline-deficient diet. Changein liver fat content was estimated by MRI with a Siemens VISION® 41.5Tclinical MR system using a modified “In and Out of Phase” procedure (daCosta et al. (2005); Fishbein et al. (1997)). This approach utilizes thedifferences in transverse magnetization intensity after an ultra-brieftime interval (FLASH; TE=2.2 ms and 4.5 ms, with a flip angle of 80°,and TR=140 ms). Processing of successive FLASH MRI images with softwarefrom Siemens Medical Solutions (Malvern, Pa., U.S.A.) was used toestimate fat content. Organ fat content was derived from measurementsacross 3-5 liver slices per subject and standardized by relating theresults to the fat content of similarly measured slices of spleen.

Laboratory analyses. Fasting blood samples were taken every 3-4 days forblood chemistries (including CPK analysis), after 10 days on the 550mg/day choline diet (baseline), and at the end of the low choline diet(depletion phase) for choline and genotyping studies. Serum was analyzedusing a dry slide colorimetric method for CPK activity by the McClendonClinical Laboratories at University of North Carolina Hospitals, whichis both Clinical Laboratory Improvement Act and College of AmericanPathologists accredited. Choline and its metabolites were analyzed andquantified directly by HPLC mass spectrometry (LC/ESI-IDMS) after theaddition of internal standards labeled with stable isotopes that wereused to correct for recovery (Koc et al. (2002)).

Genotyping. Peripheral lymphocytes were isolated from blood byFicoll-Hypaque gradient using VACUTAINER® CPT™ tubes with sodium citrate(Becton Dickinson, Franklin Lakes, N.J., U.S.A.) (Fotino et al. (1971);Ting & Morris et al. (1971)) and genomic DNA extracted using PUREGENE®(Gentra Systems, Minneapolis, Minn., U.S.A.) according to themanufacturer's instructions. SNP analyses were carried out as describedbelow. Table 5 lists SNPs studied for this Example. Briefly, for thePEMT and CHDH genes, DNA sequencing was performed on double-stranded DNAtemplates obtained from genomic DNA by polymerase chain reaction (PCR)amplification. A negative control without DNA and a positive controlwith human DNA (PROMEGA Inc., Madison, Wis., U.S.A.) for each PCR setwere included. PCR products were purified with QIAQUICK® PCRPurification Kit 250 (QIAGEN Inc., Valencia, Calif., U.S.A.) afterelectrophoresis in 0.8% or 3% agarose depending on the size of thefragment. Sequencing reactions were performed by the University of NorthCarolina at Chapel Hill Genome Analysis Facility, using a capillarysequencing machine (model 3100, Applied Biosystems, Foster City, Calif.,U.S.A.). Sequence results were interpreted using the program SEQUENCHER™(Gene Code Corp., Ann Arbor, Mich., U.S.A.). Basic local alignmentsearch tool searches were performed using the National Center forBiotechnology (NCBI) program available through the NCBI website.

TABLE 5 Base pair and Gene rs number sequence change MTHFD1 rs2236225+1958 G → A PEMT rs12325817 −744 G → C^(b) PEMT rs2278952 +164 C → T^(b)PEMT rs7946 +5465 G → A^(b) PEMT not yet designated −314 C → T^(b) PEMTnot yet designated +29 C → G^(b) CHDH rs9001 +318 A → C CHDH rs12676+432 G → T BHMT rs3733890 +742 G → A

Promoter of the PEMT gene. Successful amplification of the 1896 by DNAfragment of the PEMT gene was performed using TAKARA™ Ex Taq polymerase(Fisher Scientific, Fair Lawn, N.J., U.S.A.) with an efficient 3′-5′exonuclease activity for increased fidelity. Based on the GENBANK®sequence (accession number NC_(—)000017), a set of primers foramplification was designed, as recommended by the manufacturers, and aset of primers for sequencing the overlapping segments in two directions(Table 6) using the WEB PRIMERS™ design program available through theStanford University website. The forward and reverse primers were5′GAGCACGTGAGCTGTCAGTGCCTTTTG3′ (SEQ ID NO:30) and5′CCAACCTCCTTCATACAACAGAGGTCC3′ (SEQ ID NO:31), respectively, and athree-step PCR was performed on an Applied Biosystems 2720 thermalcycler (Foster City, Calif., U.S.A.) under the following conditions: 96°C. for 2 min; 30 cycles (94° C. for 30 s, 60° C. for 1 min, 72° C. for 2min); extend 72° C. for 7 min, and soak at 4° C. For the sequencedetermination of PEMT rs12325817 (SEQ ID NO:1), an additional primer wasused (PEMT PRO seq-F2 (SEQ ID NO:35; Table 6) to verify the sequence ina region containing Alu repeats and a poly-A tail.

TABLE 6 Position of primer (bp) Primer name Sequence of primer 5′→3′7728-7757 PEMT PRO - F3 GGAGTTATGGATCTAGGGAACTGGAGCAGC (SEQ ID NO: 32)7711-7730 PEMT PROseq - F1 ATTTCACCCTCCTGAAAGGA (SEQ ID NO: 33)8102-8082 PEMT PROseq - R1 TGACCAATCTAAGCCCAGGTT (SEQ ID NO: 34)8092-8112 PEMT PROseq - F2 TAGATTGGTCATGGGAGGCTT (SEQ ID NO: 35)8493-8474 PEMT PROseq - R2 ACAACATGGTGACACTCCGT (SEQ ID NO: 36)8503-8522 PEMT PROseq - F3 TCTCGAACTCCTGACCATCA (SEQ ID NO: 37)8878-8860 PEMT PROseq - R3 CCCGTAATCCCAGCACTTT (SEQ ID NO: 38) 8915-8935PEMT PROseq - F4 GAGGAAAAAGACTCTGGCACA (SEQ ID NO: 39) 9300-9280PEMT PROseq - R4 TTTACTCCATTGAGGGGTGCA (SEQ ID NO: 40) 9084-9101PEMT PROseq - F5 TGATGGATCCCAGGAGGA (SEQ ID NO: 41) 9510-9490PEMT PROseq - R5 GGCTTTCTGCTACCCAGTAAT (SEQ ID NO: 42) 9525-9498PEMT PRO - R1 ACAACAGAGGTCCCGGCTTTCTGCTAC (SEQ ID NO: 43) 8438-8458PEMT PROseqMid - F3 ACAACAGAGGTCCCGGCTTTCTGCTAC (SEQ ID NO: 44)8824-8802 PEMT PROseqMid - R3 TCAGAGATCAGCCTGGCCAATAT (SEQ ID NO: 45)8461-8480 PEMT PROseqMid - F4 ATTTTTAGTAGAGACGGAGT (SEQ ID NO: 46)8840-8821 PEMT PROseqMid - R4 ATCACAAGGCCAGGAGTCAG (SEQ ID NO: 47)8374-8394 PEMT PRO SNP1- F ACTTCCTGGGTTGAAGCGATT (SEQ ID NO: 48)8597-8579 PEMT PRO SNP1- R TTTATTCTCTGGCCGTGCC (SEQ ID NO: 49)

PEMT. The coding region of PEMT containing the SNP rs7946 was amplifiedwith the oligonucleotides 5′GGAGCACTTTGCCCCAGAATC3′ (SEQ ID NO:50) and5′GACTTGGAGCCTTCAGAGCG3′ (SEQ ID NO:51) as forward and reverse primers,respectively (Song et al. (2005)). The sequences obtained were comparedwith ones stored in the NCBI database available through the NCBI website(accession number AF294467) using ClustalW multiple sequence alignmentsoftware available through the European Bioinformatics Institutewebsite.

CHDH. Amplification of the 370 by DNA fragment containing SNPs rs9001(SEQ ID NO:13) and rs12676 (SEQ ID NO:14) in the CHDH gene was performedusing BD ADVANTAGE™ GC Genomic PCR Kit (BD Biosciences, Mountain View,Calif., U.S.A.). Based on the GENBANK® sequence (accession numberNC_(—)000003), the following primers were designed for amplification andsequencing: 5′AGTCATCTCATTCCCCTCCGTGGATCAGA3′ (forward primer; SEQ IDNO:52) and 5′TAGCACCAGTTGTACCTGTCGTCGCACA3′ (reverse primer; SEQ IDNO:53). A two-step PCR was done with the following conditions: 94° C.for 1 min; 30 cycles (94° C. for 30 s, 68° C. for 3 min); extend 70° C.for 5 min and soak at 15° C. The SNPs were numbered with the mRNAlocation (318 and 432, respectively; NT_(—)018397).

BHMT. For the variant rs3733890 (SEQ ID NO:26) in exon 6 of BHMT(GENBANK® accession number NT_(—)006713), the targeted DNA sequence:5′GCCACTTTGACCCCACCATTAGT3′ (SEQ ID NO:54) and5′TGGGAATTCTGGGAGATCGATG3′ (SEQ ID NO:55) as forward and reverseprimers, respectively, were amplified by multiplex PCR, purified, thenanalyzed with matrix-assisted laser desorption/ionization time-of-flightmass spectrometry (Meyer al. (2004)). Samples were analyzed induplicate.

Statistical analysis. Data for continuous variables are expressed asmean+/−SE, and the statistical significance of differences betweensubjects on the two different diets were assessed using paired t test. Atwo-sample t test based on the differences between choline andmetabolite concentrations in subjects on the baseline and depletiondiets was used to compare the depleted with organ dysfunction anddepleted without organ dysfunction groups. Genotype differencesassociated with organ dysfunction associated with choline deficiencywere calculated using Fisher's Exact Test to determine statisticalsignificance (Lowry (2004). For P<0.05, odds ratios and 95% confidenceintervals were calculated as the odds of showing signs of deficiency forsubjects with the risk allele divided by the odds of showing signs ofdeficiency for subjects without the risk allele. The Kruskal-Wallis testwas used to compare differences in continuous variables by genotype(Kruskal & Wallis (1952)).

Example 4

Of the 57 participants, 68% developed organ dysfunction when fed the lowcholine diet and this resolved when choline was added back to theirdiets. Plasma betaine concentrations decreased almost 50% in response tothe low choline diet (from 60+/−3 to 32+/−2 nmol/ml; P<0.001) andcholine concentrations decreased almost 30% (from 9.8+/−0.3 to 7.1+/−0.2nmol/ml; P<0.001). These decreases were irrespective of whether or notsubjects developed organ dysfunction on the low choline diet. Plasmaphosphatidylcholine concentrations were 9% lower when subjects were fedthe low choline diet (1691+/−41 vs. 1868+/−45 nmol/ml than when onbaseline diet; P<0.001); those subjects who developed organ dysfunctionon the low choline diet had a 3-fold greater decrease inphosphatidylcholine (−228+/−47 nmol/ml) than those who did not (−64+/−31nmol/ml; P<0.029 by t test). Plasma choline and phosphatidylcholineconcentrations did not differ from baseline after subjects were repletedwith choline-containing diets. Significant changes in choline, betaine,or phosphatidylcholine concentrations were not detected in plasmabetween genotypes (note that there was no significant change in plasmabetaine concentrations associated with the BHMT genotype tested).

Gender was one modifier of susceptibility to developing organdysfunction when fed a low choline diet. When deprived of dietarycholine, 77% of men and 80% of postmenopausal women developed fattyliver or muscle damage, whereas only 44% of premenopausal womendeveloped such signs of organ dysfunction associated with cholinedeficiency. Note that within each gender grouping, a significant numberof subjects were resistant to developing organ dysfunction, suggestingthat other factors, such as genetic polymorphisms, contribute tosusceptibility to developing organ dysfunction when fed a low cholinediet.

For each SNP, allelic association was tested for correlation withsusceptibility to developing organ dysfunction associated with eating alow choline diet. Two SNPs in the PEMT promoter region were identifiedand tested: rs12325817 (G-774C; SEQ ID NO:1) and an SNP at positionC-314T. A SNP in exon 4 (G54653; rs7946; SEQ ID NO:3) and two SNPs inexon 2, which adjoined the promoter, rs2278952 (C164T; SEQ ID NO:2) andC29G, were found and tested as well. For rs12325817 (G-774C; SEQ IDNO:1), the variant C allele was relatively common in our studypopulation, where 18% were CC, 56% GC, and 26% GG genotype. The SNPs atposition −314 in the PEMT promoter and +29 of exon 2 were rare, eachoccurring as a heterozygous allele in one subject (0.032 frequency).Neither developed organ dysfunction when on the low choline diet. Thers2278952 SNP (C164T; SEQ ID NO:2) occurred at a frequency of 0.25 inwomen. It, too, was a heterozygous allele and was not associated withchanges in susceptibility to developing organ dysfunction when on thelow choline diet.

In all women, 18 of the 23 (78%) carriers of the PEMT-744C allele(rs12325817; SEQ ID NO:1) developed organ dysfunction when fed a lowcholine diet (odds ratio 25, P=0.002; Table 7). In postmenopausal women,11 of 12 (92%) of the allele carriers developed organ dysfunction whenfed a low choline diet, and the two women without this allele did not.In the eight premenopausal women who were heterozygous for the allele(GC genotype), half developed organ dysfunction and half did not whenfed a low choline diet, while the two premenopausal women who werehomozygous for the allele developed organ dysfunction. Overall, thethree women homozygous for this allele (CC genotype) developed organdysfunction when fed a low choline diet, and seven of the eight femaleswithout this allele (GG genotype) did not (Table 7). There was no effectin men.

TABLE 7 Signs of p value choline OR (95% deficiency GG GC CC CI) Allsubjects (57) Yes 7 25 7 0.10 No 8 7 3 Men (26) Yes 6 10 4 0.49 No 1 2 3All women (31) Yes 1 15 3  0.002 No 7 5 0 25 (2, 256)  Pre menopausal(16) Yes 1 4 2 0.10 No 5 4 0 Postmenopausal (15) Yes 0 11 1 0.03 No 2 10 42 (1, 1348)*

The first of two SNPs in the coding region of the CHDH gene (rs9001;A318C; SEQ ID NO:13) had a protective effect on susceptibility todeveloping organ dysfunction when fed a low choline diet in all subjectswho carried the C allele (Table 8). No significant differences werefound when the participants were grouped by gender or menopausal status.Although the second CHDH variant (rs12676; G432T; SEQ ID NO:14) waswithin 115 base pairs of SNP rs9001 (A318C; SEQ ID NO:13), it was formedindependently (no difference in Hardy-Weinberg expected distribution forthe population). Among all subjects, this SNP was not associated withsusceptibility to developing organ dysfunction associated with cholinedeficiency. However, among premenopausal women, 5 of the 6 (83%) whowere heterozygous for this variant developed organ dysfunction on a lowcholine diet compared with 2 of 10 (20%) who did so without this riskallele (odds ratio 20, P=0.04; Table 8).

TABLE 8 CHDH A318C rs9001 CHDH G432T rs12676 Signs of p value p valuecholine OR (95% OR (95% deficiency AA AC CC CI) GG GT TT CI) Allsubjects Yes 34 4 1 0.03 19 19 1 0.23 (57) No 10 6 2 0.2 (0.05, 13 5 00.7) Men (26) Yes 18 2 0 0.22 10 9 1 1.00 No 4 2 0 3 3 0 All women (31)Yes 16 2 1 0.13 9 10 0 0.07 No 6 4 2 10 2 0 Pre- Yes 6 1 0 0.39 2 5 00.04 menopausal No 4 3 2 8 1 0 20 (1, (16) 282) Post- Yes 10 1 1 0.52 75 0 1.00 menopausal No 2 1 0 2 1 0 (15)

There was no association between the SNP tested in exon 4 of the PEMTgene (rs7946, G5465A; SEQ ID NO:3) and susceptibility to cholinedeficiency (Table 9), nor was the BHMT variant (rs3733890; G742A; SEQ IDNO:26) associated with changes in susceptibility to choline deficiency(Table 9).

TABLE 9 PEMT rs7946, BHMT G742A Signs of G5465A rs3733890 choline p pdeficiency GG GA AA value GG GA AA value All subjects Yes 5 16 15 0.8621 11 4 0.84 (54) No 3 9 6 9 7 2 Men (26) Yes 4 8 8 1.00 12 6 2 1.00 No1 3 2 4 1 1 All women Yes 1 8 7 0.75 9 5 2 0.65 (28) No 2 6 4 5 6 1 Pre-Yes 0 5 2 0.63 4 2 1 0.79 menopausal No 2 4 3 3 5 1 (16) Post- Yes 1 3 50.66 5 3 1 1.00 menopausal No 0 2 1 2 1 0 (12)

Discussion for Example 4

Common genetic polymorphisms have been reported to influence humanrequirements for nutrients. For example, a common SNP in themethyltetrahydrofolate reductase gene increases dietary requirements forthe vitamin folic acid (Shelnutt et al. (2003)). However, these SNPsusually have very modest effects on nutrient needs. As disclosedhereinabove in Examples 1-3, it was determined that individuals who werecarriers of the MTHFD1 1958A allele were more likely than non-carriersto develop signs of choline deficiency. The present Example disclosesthe identification of genetic variations in the PEMT and CHDH genes thatare associated with developing organ dysfunction when choline is removedfrom the diet of subjects. These polymorphisms influence thesusceptibility of developing organ dysfunction in subjects when fed alow choline diet, and thus they increase the dietary requirement forcholine needed to sustain optimal health in subjects carrying thesealleles.

In particular, women with a common variant in the promoter region of thePEMT gene rs12325817 (G-774C; SEQ ID NO:1) were at significantlyincreased risk of developing organ dysfunction when dietary intake ofcholine is insufficient. PEMT activity is responsible for endogenousbiosynthesis of choline moiety (Zeisel & Blusztajn (1994)), and thisactivity is increased by estrogen treatment (36). The promoter region ofthis gene is likely to have an estrogen response element (ERE). Indeed,the rs12325817 (G-774C; SEQ ID NO:1) SNP is located within 50 by of aputative ERE, which contains a perfect half-site consensus sequence, butfour of five bases differ in the other half-site. Without wishing to bebound by any particular theory, given the sexually dimorphic effect ofPEMT rs12325817 (G-774C; SEQ ID NO:1), it is possible that this SNPalters the estrogen responsiveness of the promoter. Again, withoutwishing to be bound by theory, premenopausal women who are heterozygousfor the PEMT rs12325817 (G-774C) C allele likely have sufficientestrogen to overcome the effects on estrogen-mediated transcriptionfactor of the single allele, whereas postmenopausal women with lowerestrogen levels are sensitive to the SNP. Men, with little estrogen,would be unaffected by an SNP that altered estrogen receptor complexbinding.

A protective effect against choline deficiency of the SNP in the CHDHgene (rs9001; A318C; SEQ ID NO:13) was determined, even though thefrequency of this allele was relatively low (0.23). A significantdecrease in susceptibility to developing organ dysfunction on a lowcholine diet in all subjects was found. A correlation with sensitivityto choline deficiency was also found with the CHDH rs12676 (G432T; SEQID NO:14) SNP.

The lack of effect of the SNP tested in exon 4 of the PEMT gene (rs7946,G5465A) was unexpected, because it was previously reported that this isa loss of function SNP and that persons with the variant A allele haveincreased risk of nonalcoholic fatty liver disease (Song et al. (2005)).Perhaps the modest decrease (30%) in activity of PEMT associated withthis SNP was overshadowed by compensatory induction of the enzyme thatis associated with choline deficiency in males (Cui & Vance (1996);Johnson & Blusztajn (1998)) and by estrogen-mediated activation of PEMTin females. With regard to the BHMT SNP effect, the protein product ofthe gene variant did not differ in either catalytic activity or betainebinding when compared to the enzyme which did not contain thepolymorphism.

The SNPs identified and disclosed herein that increased susceptibilityto developing organ dysfunction in human subjects fed low choline dietsare believed to be of clinical importance. Humans fed intravenously(total parenteral nutrition) with solutions that deliver less cholinethan the adequate intake concentration often develop liver dysfunctionthat sometimes resolves when a choline source is added to their feedingsolution (Buchman et al. (2001)). Subjects carrying the identified SNPsare the ones most likely to be susceptible to this complication ofparenteral nutrition.

These SNPs, combined with poor dietary intake of choline, can contributeto adverse outcomes during pregnancy, a time when choline demand is high(Shaw et al. (2004); Zeisel et al. (1995)). Deficient maternal dietaryintake of choline during pregnancy in humans has been associated with a4-fold increased risk of having a baby with a neural tube defect (Shawet al. (2004)). In rodent models, maternal dietary choline intakeinfluenced brain development. More choline (4 dietary levels) duringdays 11-17 of gestation in the rodent increased hippocampal progenitorcell proliferation (Albright et al. (1999a); Albright et al. (1999b)),decreased apoptosis in these cells (Albright et al. (1999a); Albright etal. (1999b)), enhanced long-term potentiation (LTP) in the offspringwhen they were adult animals (Jones et al. (1999); Pyapali et al.(1998); Montoya et al. (2000)), and enhanced visuospatial and auditorymemory by as much as 30% in the adult animals throughout their lifetime(Meck & Williams (1999); Meck & Williams (1997a); Meck & Williams(1997b); Meck & Williams (1997c); Meck et al. (1998); Meck & Williams(2003); Williams et al. (1998)). Mothers fed choline-deficient dietsduring late pregnancy have offspring with diminished progenitor cellproliferation and increased apoptosis in fetal hippocampus (Albright etal. (1999a); Albright et al. (1999b)), insensitivity to LTP when theywere adult animals (Jones et al. (1999)), and decremented visuospatialand auditory memory (Meck & Williams (1999)). For these reasons,identification of common polymorphisms that increase dietaryrequirements for choline during pregnancy, such as for example thosedisclosed herein, enables the identification of women for whom adequatedietary choline intake should be assured.

In summary, it is disclosed in the present Example for the first timethat SNPs in the phosphatidylethanolamine N-methyltransferase (PEM7) andcholine dehydrogenase (CHDH) genes are associated with alteredsusceptibility to developing organ dysfunction on a low choline diet,and they affect dietary requirements for the nutrient choline. TheseSNPs are common, and their effects should be considered when settingdietary reference intake levels. In addition, since the genes ofinterest have many more polymorphisms than were specifically tested,unmeasured but causal genetic variation can be in linkage disequilibriumwith the exemplary SNPs specifically genotyped. As such, the presentlydisclosed subject matter is intended to be inclusive of all cholinemetabolism gene polymorphisms correlated with cholinedeficiency-associated health effects, including those in linkagedisequilibrium with polymorphisms exhibiting direct effects on peptidefunction.

REFERENCES

All references cited in the specification, including but not limited toU.S. and foreign patents and patent application publications, scientificjournal articles, and database entries (including all annotationspresented therein), are incorporated herein by reference to the extentthat they supplement, explain, provide a background for or teachmethodology, techniques and/or compositions employed herein.

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It will be understood that various details of the subject matterdisclosed herein can be changed without departing from the scope of thepresently disclosed subject matter. Furthermore, the foregoingdescription is for the purpose of illustration only, and not for thepurpose of limitation.

1. A method of predicting susceptibility of a subject to develop one ormore choline deficiency-associated health effects, comprising: (a)determining a genotype of the subject with respect to at least onecholine metabolism gene; and (b) comparing the genotype of the subjectwith at least one reference genotype associated with susceptibility todevelop the one or more choline deficiency-associated health effects,wherein the reference genotype is at least one genotype of a cholinemetabolism gene, whereby susceptibility of the subject to develop theone or more choline deficiency-associated health effects is predicted.2. The method of claim 1, wherein determining the genotype of thesubject comprises: identifying at least one polymorphism of the at leastone choline metabolism gene; (ii) identifying at least one haplotype ofthe at least one choline metabolism gene; (iii) identifying at least onepolymorphism unique to at least one haplotype of the at least onecholine metabolism gene; (iv) identifying at least one polymorphismexhibiting high linkage disequilibrium to at least one polymorphismunique to the at least one choline metabolism gene; (v) identifying atleast one polymorphism exhibiting high linkage disequilibrium to the atleast one choline metabolism gene; or (vi) combinations thereof.
 3. Themethod of claim 1, wherein the choline metabolism gene is selected fromthe group consisting of phosphatidylethanolamine N-methyltransferase(PEMT), choline dehydrogenase (CHDH), 5,10-methylenetetrahydrofolatedehydrogenase 1 (MTHFD1), and combinations thereof, and wherein thereference genotype is selected from the group consisting of a PEMTgenotype, a CHDH genotype, an MTHFD1 genotype, and combinations thereof.4. The method of claim 3, wherein the reference genotype is a PEMTgenotype comprising a G-774C (rs12325817) polymorphism.
 5. The method ofclaim 4, wherein the determined genotype of the subject with respect toPEMT comprises at least one copy of a PEMT rs12325817 C allele and thesubject is predicted to be susceptible to develop one or more cholinedeficiency-associated health effects.
 6. The method of claim 3, whereinthe reference genotype is a CHDH genotype comprising a G432T (rs12676)polymorphism.
 7. The method of claim 6, wherein the determined genotypeof the subject with respect to CHDH comprises at least one copy of aCHDH rs12676 T allele and the subject is predicted to be susceptible todevelop one or more choline deficiency-associated health effects.
 8. Themethod of claim 3, wherein the reference genotype is a CHDH genotypecomprising a A318C (rs9001) polymorphism.
 9. The method of claim 8,wherein the determined genotype of the subject with respect to CHDHcomprises at least one copy of a CHDH rs9001 C allele and the subject ispredicted to be resistant to develop one or more cholinedeficiency-associated health effects.
 10. The method of claim 3, whereinthe reference genotype is a MTHFD1 genotype comprising a G1958A(rs2236225) polymorphism.
 11. The method of claim 10, wherein thedetermined genotype of the subject with respect to MTHFD1 comprises atleast one copy of a MTHFD1 rs2236225 A allele and the subject ispredicted to be susceptible to develop one or more cholinedeficiency-associated health effects.
 12. The method of claim 1, whereinthe one or more choline deficiency-associated health effects areselected from the group consisting of transmembrane signalingdysfunction, cholinergic neurotransmission dysfunction, lipid transportdysfunction, lipid metabolism dysfunction, organ dysfunction, liverdysfunction, fatty liver, congenital birth defects, and combinationsthereof.
 13. The method of claim 1, wherein the subject is apremenopausal female subject.
 14. The method of claim 13, wherein thedetermined genotype of the subject comprises at least one copy of a PEMTrs12325817 C allele, at least one copy of a MTHFD1 rs2236225 A allele,or combinations thereof and the subject is predicted to be susceptibleto develop the one or more choline deficiency-associated health effects.15. The method of claim 13, wherein the subject is a pregnant subjectand the one or more choline deficiency-associated health effectscomprise one or more congenital birth defects to a fetus carried by thesubject.
 16. The method of claim 15, wherein the congenital birthdefects comprise a neural tube defect.
 17. The method of claim 1,wherein the subject is receiving substantially all nutritionalsustenance parenterally.
 18. The method of claim 17, wherein the one ormore choline deficiency_(;) associated health effects comprise liverdysfunction.
 19. The method of claim 1, wherein the one or more cholinedeficiency-associated health effects are associated with an insufficientdietary intake of choline by the subject.
 20. A method of treating oneor more choline deficiency-associated health effects in a subject,comprising: (a) determining a genotype of the subject with respect to atleast one choline metabolism gene; (b) comparing the determined genotypeof the subject with at least one reference genotype associated withsusceptibility to develop one or more choline deficiency-associatedhealth effects, wherein the reference genotype is at least one genotypeof a choline metabolism gene; and (c) administering to the subject aneffective amount of a choline supplement composition, based on thedetermined genotype being associated with susceptibility to develop oneor more choline deficiency-associated health effects.
 21. The method ofclaim 20, wherein determining the genotype of the subject comprises: (i)identifying at least one polymorphism of the at least one cholinemetabolism gene; (ii) identifying at least one haplotype of the at leastone choline metabolism gene; (iii) identifying at least one polymorphismunique to at least one haplotype of the at least one choline metabolismgene; (iv) identifying at least one polymorphism exhibiting high linkagedisequilibrium to at least one polymorphism unique to the at least onecholine metabolism gene; (v) identifying at least one polymorphismexhibiting high linkage disequilibrium to the at least one cholinemetabolism gene; or (vi) combinations thereof.
 22. The method of claim20, wherein the choline metabolism gene is selected from the groupconsisting of phosphatidylethanolamine N-methyltransferase (PEMT),choline dehydrogenase (CHDH), 5,10-methylenetetrahyd rofolatedehydrogenase 1 (MTHFD1), and combinations thereof.
 23. The method ofclaim 22, wherein the reference genotype is selected from the groupconsisting of a PEMT genotype, a CHDH genotype, an MTHFD1 genotype, andcombinations thereof.
 24. The method of claim 23, wherein the referencegenotype is a PEMT genotype comprising a G-774C (rs12325817)polymorphism.
 25. The method of claim 24, wherein the determinedgenotype of the subject with respect to PEMT comprises at least one copyof a PEMT rs12325817 C allele, and the subject is administered thecomposition.
 26. The method of claim 22 wherein the reference genotypeis a CHDH genotype comprising a G432T (rs12676) polymorphism.
 27. Themethod of claim 26, wherein the determined genotype of the subject withrespect to CHDH comprises at least one copy of a CHDH rs12676 T allele,and the subject is administered the composition.
 28. The method of claim23, wherein the reference genotype is a CHDH genotype comprising a A318C(rs9001) polymorphism.
 29. The method of claim 28, wherein thedetermined genotype of the subject with respect to CHDH comprises atleast one copy of a CHDH rs9001 C allele, and the subject is notadministered the composition.
 30. The method of claim 23, wherein thereference genotype is a MTHFD1 genotype comprising a G1958A (rs2236225)polymorphism.
 31. The method of claim 30, wherein the determinedgenotype of the subject with respect to MTHFD1 comprises at least onecopy of a MTHFD1 rs2236225 A allele and the subject is administered thecomposition.
 32. The method of claim 20, wherein the one or more cholinedeficiency-associated health effects are selected from the groupconsisting of transmembrane signaling dysfunction, cholinergicneurotransmission dysfunction, lipid transport dysfunction, lipidmetabolism dysfunction, organ dysfunction, liver dysfunction, fattyliver, congenital birth defects, and combinations thereof.
 33. Themethod of claim 20, wherein the subject is a premenopausal femalesubject.
 34. The method of claim 33, wherein the determined genotype ofthe subject comprises at least one copy of a PEMT rs12325817 C allele,at least one copy of a MTHFD1 rs2236225 A allele, or combinationsthereof and the subject is administered the composition.
 35. The methodof claim 33, wherein the subject is a pregnant subject and the one ormore choline deficiency-associated health effects comprise one or morecongenital birth defects to a fetus carried by the subject.
 36. Themethod of claim 35, wherein the congenital birth defects comprise aneural tube defect.
 37. The method of claim 20, wherein the subject isreceiving substantially all nutritional sustenance parenterally.
 38. Themethod of claim 37, wherein the one or more cholinedeficiency-associated health effects comprise liver dysfunction.
 39. Themethod of claim 20, wherein the one or more cholinedeficiency-associated health effects are associated with an insufficientdietary intake of choline by the subject.
 40. A method of predictingactivity of a choline metabolism polypeptide in a subject, comprising:(a) determining a genotype of the subject with respect to at least onecholine metabolism gene; and (b) comparing the genotype of the subjectwith at least one reference genotype associated with activity of acholine metabolism polypeptide, wherein the reference genotype is atleast one genotype of a choline metabolism gene, whereby activity of thecholine metabolism polypeptide is predicted.
 41. The method of claim 40,wherein determining the genotype of the subject comprises: (i)identifying at least one polymorphism of the at least one cholinemetabolism gene; (ii) identifying at least one haplotype of the at leastone choline metabolism gene; (iii) identifying at least one polymorphismunique to at least one haplotype of the at least one choline metabolismgene; (iv) identifying at least one polymorphism exhibiting high linkagedisequilibrium to at least one polymorphism unique to the at least onecholine metabolism gene; (v) identifying at least one polymorphismexhibiting high linkage disequilibrium to the at least one cholinemetabolism gene; or (vi) combinations thereof.
 42. The method of claim20, wherein the choline metabolism gene is selected from the groupconsisting of phosphatidylethanolamine N-methyltransferase (PEMT),choline dehydrogenase (CHDH), 5,10-methylenetetrahydrofolatedehydrogenase 1 (MTHFD1), and combinations thereof.
 43. The method ofclaim 42, wherein the reference genotype is selected from the groupconsisting of a PEMT genotype, a CHDH genotype, an MTHFD1 genotype, andcombinations thereof.
 44. The method of claim 43, wherein the referencegenotype is a PEMT genotype comprising a G-774C (rs12325817)polymorphism.
 45. The method of claim 43 wherein the reference genotypeis a CHDH genotype comprising a G432T (rs12676) polymorphism.
 46. Themethod of claim 43, wherein the reference genotype is a CHDH genotypecomprising a A318C (rs9001) polymorphism.
 47. The method of claim 43,wherein the reference genotype is a MTHFD1 genotype comprising a G1958A(rs2236225) polymorphism.
 48. The method of claim 40, wherein thesubject is a premenopausal female subject.
 49. The method of claim 48,wherein the subject is a pregnant subject.
 50. The method of claim 40,wherein the subject is receiving substantially all nutritionalsustenance parenterally.